Chapter 5122-14 | Licensing of Psychiatric Hospitals and Units

Rule 5122-14-01 | Definitions and applicability.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) The provisions of Chapter 5122-14 of the Administrative Code apply to each inpatient psychiatric service provider licensed pursuant to section 5119.33 of the Revised Code by the department of mental health and addiction services.

(B) The following definitions apply to Chapter 5122-14 of the Administrative Code:

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

(2) "Abused child" has the same meaning as in section 2151.031 of the Revised Code.

(3) "ACHC" means the accreditation commission for health care.

(4) "Admission" means acceptance by the inpatient psychiatric service provider of a person with the intent of providing at least twenty-four hours continuous care and treatment to that person.

(5) "Advance directives" means a legal document an adult can use to direct in advance the decisions about their mental or physical health treatment if in the future they lack the capacity to make their own health care decisions.

(6) "Certified nurse practitioner" has the same meaning as in section 4723.01 of the Revised Code.

(7) "Chemical restraint" means any medication that alters the functioning of the central nervous system in a manner that limits physical and cognitive functioning to the degree that the patient cannot attain the patient's highest practicable physical, mental, and psychosocial well-being.

(8) "Child and adolescent psychiatrist" means a psychiatrist who is certified in child and adolescent psychiatry by the American board of psychiatry and neurology or has successfully completed training in a child and adolescent psychiatry program approved by the residency review committee of the accreditation council for graduate medical education of the American medical association. A child and adolescent psychiatrist is also a psychiatrist as defined in this rule.

(9) "Clear treatment reasons" means that a patient would present a substantial risk of physical harm to themselves or others, or that effective treatment of the patient would be substantially precluded.

(10) "Clinical nurse specialist" has the same meaning as in section 4723.01 of the Revised Code.

(11) "Clinical privileges" means authorization granted to a practitioner to provide specific health care services in the organization within well-defined limits, based on the following factors, as applicable: license, certification, registration, education, training, experience, competence, health status, and judgment.

(12) "CMS" means the centers for medicare and medicaid services, a federal agency within the U.S. department of health and human services.

(13) "Community addiction services provider" has the same meaning as in section 5119.01 of the Revised Code.

(14) "Community mental health services provider" has the same meaning as in section 5119.01 of the Revised Code.

(15) "Counselor" means an individual who is licensed as a professional counselor or a professional clinical counselor in accordance with Chapter 4757. of the Revised Code.

(16) "Cultural sensitivity" means an awareness, understanding, and responsiveness to the beliefs, values, customs, and institutions (family, religious, etc.) of a group of people, particularly those of a race or ethnic group different from one's own, or those identified cultures of persons with specific disabilities such as deafness.

(17) "Culturally relevant" means incorporating awareness, understanding, and responsiveness to the beliefs, values, customs, and institutions (family, religious, etc.) and ethnic heritage of individuals or those identified cultures of persons with specific disabilities such as deafness, into training, treatment, and services designed to impact upon, or meet the needs of individuals or groups.

(18) "Department" means the Ohio department of mental health and addiction services.

(19) "Det norske veritas (DNV) healthcare, inc." means the organization, a division of det norske veritas, which operates the national integrated accreditation for healthcare organizations program.

(20) "Developmental disability" has the same meaning as in section 5123.01 of the Revised Code.

(21) "Director" means the director of the Ohio department of mental health and addiction services.

(22) "Dietitian" means an individual who is licensed as a dietitian in accordance with Chapter 4759. of the Revised Code.

(23) "Emergency" means an impending or crisis situation that creates circumstances demanding immediate action.

(24) "Expressive therapist" means an individual who provides treatment intervention through the use of such activities as art, music, or dance and who (a) is certified or registered by the national expressive therapist association, certification board for music therapists, American arts therapy association, American dance therapy association or (b) is licensed, certified or registered by another recognized state or national body to practice expressive therapy.

(25) "Family members" means persons related by family to a patient.

(26) "Grievance" means a written record of dissatisfaction with mental health services expressed by a patient, family member, significant other, patient rights advocate, or other interested person or agency.

(27) "Guardian" means any person, association, or corporation appointed by the probate court to have responsibility for the care and management of a minor or a person declared incompetent in accordance with Chapter 2111. of the Revised Code.

(28) "Incident" means any event that poses a danger to the health and safety of patients, staff, or visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the hospital.

(29) "Informed consent" means the voluntary, knowing, reasoned choice of a person, or, as appropriate, the person's legal guardian to a proposed treatment or procedure.

(30) "Inpatient psychiatric service provider" or "hospital" means a psychiatric hospital or psychiatric inpatient unit administered by a general hospital, community mental health service provider, or other facility that provides inpatient psychiatric services.

(31) "Involuntary" means against an individual's will or without having been provided informed consent.

(32) "Joint commission" (TJC) means the joint commission, formerly known as the joint commission on accreditation of healthcare organizations (JCAHO).

(33) "License" means the department's written approval and authorization for an inpatient psychiatric service provider to receive persons with a mental disorder for care and treatment.

(34) "Licensed practical nurse" has the same meaning as in section 4723.01 of the Revised Code.

(35) "Mechanical restraint," "physical restraint," and "prone restraint" have the same meanings as in rule 5122-26-16 of the Administrative Code.

(36) "Medical record" means the account of a patient's hospitalization, compiled by health care professionals, including but not limited to a patient's history, present illness, findings on examination, details of care, services and treatment, and progress notes.

(37) "Medication" means therapeutic drugs (or agents or compounds) dispensed, personally furnished, or administered pursuant to a prescription or order by an appropriately licensed independent practitioner.

(38) "Neglect" means a purposeful or negligent disregard of duty imposed on an employee or staff member by statute, rule, or professional standard and owed to a patient by that employee or staff member.

(39) "Nursing staff" means clinical nurse specialists, certified nurse practitioners, registered nurses, licensed practical nurses, nursing assistants, and other nursing personnel who perform patient care.

(40) "Occupational therapist" has the same meaning as in section 4755.04 of the Revised Code.

(41) "Occupational therapy assistant" has the same meaning as in section 4755.04 of the Revised Code.

(42) "Patient" means a person admitted to a hospital or inpatient unit either voluntarily or involuntarily who is under observation or receiving treatment or is receiving any other mental health services by the inpatient psychiatric service provider.

(43) "Patient rights specialist" means a person designated by each inpatient psychiatric service provider to safeguard patient rights and to assist patients in exercising their rights, including the rights in this chapter and in Chapter 5122. of the Revised Code.

(44) "Physician" means a person authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery or a medical officer of the government of the United States while in this state in the performance of his or her official duties.

(45) "Psychiatric intensive care" means a program within a defined secure physical space (normally including patient lounge and sleeping room space) utilized to provide a more intense form of care for those patients requiring closer observation, decreased environmental stimulation, or a more intensive staff to patient ratio.

(46) "Psychiatrist" has the same meaning as in section 5122.01 of the Revised Code.

(47) "Psychiatrist with clinical privileges in adolescent psychiatry" means a psychiatrist who is qualified through training and experience specific to the needs of adolescent patients and has specific hospital clinical privileges to provide treatment to adolescent patients.

(48) "Psychiatrist with clinical privileges in geriatric psychiatry" means a psychiatrist who is qualified through the American board of psychiatry and neurology or through other documented training or experience specific to the needs of geriatric patients and has specific hospital clinical privileges to provide treatment to geriatric patients.

(49) "Psychologist" means an individual who holds a current, valid license to practice psychology issued under section 4732.12 of the Revised Code.

(50) "Psychotropic medication" means that group of medications having a specific and intended effect on central nervous system functions that are ordinarily used to alter disorders of thought, perception, mood, or behavior.

(51) "Recovery" means a personal process of overcoming the negative impact of a psychiatric disability despite its continued presence.

(52) "Recreational therapist" means an individual who is registered by the Ohio recreational therapy registration board or certified by the national council for therapeutic recreation certification or who is licensed, certified, or registered by another recognized state or national body to practice recreational therapy.

(53) "Registered nurse (R.N.)" has the same meaning as in section 4723.01 of the Revised Code.

(54) "Rehabilitation therapist" means an occupational therapist, occupational therapy assistant, recreational therapist, or expressive therapist as defined in this rule. Such individuals are to comply with current, applicable scope of practice and supervisory requirements as identified by their appropriate licensing, certifying, or registering bodies.

(55) "Rehabilitation therapy services" means structured activities designed to help a patient develop or maintain functional living skills including physical, social, and creative skills through participation in activities of daily living, vocational, recreational, social, expressive, or other activities designed to promote patient recovery, resiliency, and independence in both the hospital and community setting.

(56) "Reportable incident" means an incident that has to be submitted to the department through the web enabled incident reporting system (WEIRS), maintained by the department, in accordance with the rules in this chapter. As referenced in division (G) of section 5119.36 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident".

(57) "Resiliency" means the personal and community qualities that enable individuals to rebound from adversity, trauma, tragedy, threats, or other stresses and to go on with life with a sense of mastery, competence, and hope.

(58) "Restraint" means any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

(59) "Seclusion" means the involuntary confinement of a patient alone in a room where the patient is physically prevented from leaving.

(60) "Significant other" means an individual who is significant and important to the well-being of the patient, as identified by the patient.

(61) "Social worker" means a person licensed under Chapter 4757. of the Revised Code to practice as a social worker or independent social worker.

(62) "Transitional hold" means a brief hold, without undue force, of a person in order to calm or comfort them; or holding a person's hand to safely escort them from one area to another. At no time may a transitional hold be a prone restraint, mechanical restraint, or physical restraint as defined in this rule. Transitional holds are not seclusion or restraint.

(63) "Treatment plan" means a written statement of goals and objectives for a patient with corresponding treatment interventions and services.

(64) "Variance" means permission granted by the director or designee in writing to an inpatient psychiatric service provider to change the conditions or specific mandates of a rule.

(65) "Waiver" means permission granted by the director or designee in writing to an inpatient psychiatric service provider to be exempted from the conditions of specific mandates of a rule.

Last updated April 24, 2024 at 8:35 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 11/1/2005

Rule 5122-14-02 | Accreditation.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) Each inpatient psychiatric service provider licensed by the department is to be accredited under a hospital accreditation program by either the joint commission (TJC), the accreditation commission for health care inc. (ACHC), or DNV healthcare USA inc. (DNV).

(B) Proof of such accreditation is to be submitted by the inpatient psychiatric service provider as indicated in paragraphs (A)(1)(h) and (B)(7) of rule 5122-14-03 of the Administrative Code.

Last updated April 24, 2024 at 8:35 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/1991, 2/17/2017

Rule 5122-14-03 | Licensure procedure.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) An inpatient psychiatric service provider wishing to establish inpatient services for the first time for persons with mental disorders will, prior to occupancy and provision of services, make application for full licensure to the department.

(1) At a minimum, an application is to consist of all of the following:

(a) A completed application form;

(b) An approved building inspection or certificate of occupancy report;

(c) An approved fire inspection report;

(d) A non-refundable annual licensure fee;

(e) A reduced line drawing showing the location and function of all patient and staff areas including the floor and social space square footage;

(f) A comprehensive plan of service;

(g) Before September 30, 2024, and only if applicable, proof of psychiatric bed registration as reported annually to the Ohio department of health;

(h) Verification of current TJC, ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation;

(i) A completed self-survey checklist;

(j) A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age, and the number of licensed beds designated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older is to equal the total number of licensed beds for the inpatient psychiatric service provider; and

(k) If applicable, the notification required by section 5119.334 of the Revised Code.

(2) The proposed inpatient psychiatric service provider will be subject to an on-site inspection by a designee of the department prior to occupancy to determine if the inpatient psychiatric service provider is in compliance with section 5119.33 of the Revised Code and the rules in this chapter.

(3) An interim license not to exceed ninety days may be issued to the inpatient psychiatric service provider upon completion and departmental approval of the mandates specified in paragraphs (A)(1) and (A)(2) of this rule.

(4) Prior to expiration of the interim license, the department may issue a full license based on review and approval by the department of both of the following:

(a) Implementation of policies and procedures; and

(b) Documentation of being in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter.

(B) For an inpatient psychiatric service provider holding a current license, annual renewal of full licensure will be based on receipt and approval by the department of all of the following:

(1) A completed application form that assures that the private inpatient psychiatric service provider remains in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter;

(2) Documentation of the substantial changes in written policies and procedures the provider has made during the current licensure period specific to the inpatient psychiatric service provider treatment and licensure rules in this chapter;

(3) An approved fire inspection report, dated within one year of licensure renewal date;

(4) An approved building inspection report, if renovations or major changes in the building have been made or a major change has been made in the use of space;

(5) The non-refundable annual licensure fee;

(6) A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age and the number of licensed beds dedicated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older is to equal the total number of licensed beds for the inpatient psychiatric service provider;

(7) Verification of current TJC, ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation; and

(8) If applicable, the notification required by section 5119.334 of the Revised Code.

The department will issue automated notices from the licensure and certification tracking system (LACTS) to the inpatient psychiatric service provider prior to the expiration of the annual license

(C) A designee of the department will conduct an on-site survey of the inpatient psychiatric service provider every three years to ensure compliance with section 5119.33 of the Revised Code and the rules in this chapter. Whenever possible, the department will give the inpatient psychiatric service provider notice at least thirty days before the survey is to occur.

(D) The department will provide to an inpatient psychiatric service provider a written communication identifying any deficiencies or non-compliance with licensure rules in this chapter subsequent to an on-site survey or whenever the inpatient psychiatric service provider is found to be in non-compliance with such rules.

(1) If deficiencies or non-compliance with such rules are present, the inpatient psychiatric service provider is to submit documentation of its corrective actions as specified by the department in its written report.

(2) When the deficiencies have been corrected, or a plan to do so has been received and granted approval by the department, the department may then issue a full or probationary license. The existing license is to remain in effect until the department grants a full, probationary, or interim license, or rescinds the license in accordance with provisions of Chapter 119. of the Revised Code.

(3) The inpatient psychiatric service provider is to fully implement its plan of correction within the timeframes specified by the department.

(E) A license will be issued to a specific inpatient psychiatric service provider for a specified total maximum daily census expressed as licensed beds and is not to be transferred, modified, or changed without prior approval from the department.

(1) Before September 30, 2024, licensed beds are to be registered annually with the Ohio department of health pursuant to section 3701.07 of the Revised Code.

(2) Before making any change in the location or the total number of licensed beds, the licensee is to seek approval from the department.

(3) The number of licensed beds refers to the actual number of set up and staffed beds available for immediate patient occupancy or that can be made available for patient occupancy within twenty-four hours.

(a) If an inpatient psychiatric service provider has temporarily designated patient bed space for other purposes to best meet space allocation needs, or if beds have been unavailable for occupancy due to renovation of psychiatric hospital or inpatient unit physical facilities, these beds may be licensed (once available for patient occupancy) upon application by the inpatient psychiatric service provider to the department.

(b) Before September 30, 2024, the total number of licensed beds is not to exceed the number of beds registered with the department of health pursuant to section 3701.07 of the Revised Code.

(4) If an inpatient psychiatric service provider wishes to cease provision of inpatient services, it is to notify the department in writing so that its license can be terminated. The inpatient psychiatric service provider is to also notify the department of health, as applicable.

(F) An inpatient psychiatric service provider may be visited at any time by a designee of the department to determine compliance with rules in this chapter. The department is to have access to, and may have copies of, any of the provider's records, regardless of format, to verify compliance with section 5119.33 of the Revised Code and the rules in this chapter. In addition, the department may conduct interviews with members of the provider's governing body, staff, and others and, with patient permission, a patient.

Last updated April 24, 2024 at 8:35 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/1991, 2/17/2017

Rule 5122-14-04 | Classification of licenses.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) Licenses are classified as follows:

(1) A probationary license, which expires within one hundred twenty days of the date of issuance, to be used in either of the following circumstances:

(a) Serious deficiencies are found during the department's on-site survey of an inpatient psychiatric service provider; or

(b) An inpatient psychiatric service provider's documented corrective action is not approved by the department.

(2) An interim license, which expires within ninety days after the date of issuance, to be used for emergency licensure purposes or administrative reasons as determined by the department.

An inpatient psychiatric service provider applying for its first license, and who has preliminary, interim, or similar accreditation, is to be issued an interim license until it obtains full accreditation from either TJC, ACHC, or DNV.

(3) A full license expires one year after the date of issuance.

(B) All licenses are renewable, except that an interim license may be renewed only twice.

(C) A license will specify authorization to admit either one or both age categories of patients based upon the provision of age appropriate diagnostic and treatment services. The child/adolescent category applies to all persons less than eighteen years of age upon admission. The adult category applies to all persons eighteen years of age and older upon admission.

(1) Persons less than eighteen years of age are to be admitted only to authorized child/adolescent designated beds;

(2) Persons eighteen years of age and older are to be admitted only to authorized adult designated beds.

(3) The following will be the only exceptions permitted for not admitting a patient to an age appropriate bed. All exceptions are based on clinical needs specific to each patient or the unavailability of age appropriate designated beds. For all exceptions there is to be documentation in the patient's medical record of the reasons for the exception and ongoing concurrent utilization review. The inpatient service provider is to maintain a log which is to contain the reason for admission, length of stay, referral arrangements, and reason for the exception. The department is to review the log annually.

(a) For child/adolescent admissions to adult beds due to the unavailability of child/adolescent beds, the concurrent utilization review is to include documentation indicating all efforts made to seek appropriate resources and linkages with child/adolescent providers for consultation including treatment planning and after hospitalization care.

(b) The inpatient psychiatric service provider is to inform the parent or legal guardian of the reasons for the decision to admit a child/adolescent to an adult designated bed and also provide information about all available child/adolescent designated beds.

(c) When the admission is an emergency and all child/adolescent designated beds are unavailable, a person less than eighteen years of age upon admission may be admitted to an adult designated bed.

(i) A sixteen or seventeen-year-old patient may remain in an adult designated bed for up to seventy-two hours, and if all child/adolescent beds remain unavailable, the admission may be extended for an additional seventy-two hours. If the admission is extended beyond the first seventy-two hours, an assessment mandated by paragraph (E)(2)(g) of rule 5122-14-13 of the Administrative Code is to be conducted, and rehabilitation therapy services and family therapy/interventions are to be available in accordance with paragraphs (K)(3) to (K)(4) of rule 5122-14-12 of the Administrative Code.

(ii) A fifteen-year-old or younger patient may remain in an adult designated bed for a maximum of forty-eight hours if all child/adolescent beds remain unavailable.

(d) A seventeen-year-old person may be electively admitted and treated in an adult designated bed if the person is functioning as an adult in such areas as employment (with limited or no school involvement), family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult designated bed, provided that such treatment best meets the patient's needs.

(e) A patient eighteen to twenty-one years old may be admitted to a child/adolescent designated bed based on developmental or other clinical needs specific to the patient.

(4) To receive authorization to admit persons less than eighteen years of age, the licensee is to have diagnostic and treatment services that meet the needs of these patients in accordance with rules 5122-14-12 and 5122-14-14 of the Administrative Code.

Last updated April 24, 2024 at 8:35 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 7/1/2011

Rule 5122-14-05 | Termination of license.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) The inpatient psychiatric service provider's existing license is to remain in effect until the department grants a full, probationary, or interim license or rescinds the license in accordance with provisions of Chapter 119. of the Revised Code.

(B) The department may revoke or refuse to grant or renew a full, probationary, or interim license in accordance with Chapter 119. of the Revised Code if any of the following is the case:

(1) An inpatient psychiatric service provider is found to not be in compliance with section 5119.33 of the Revised Code or any or all rules in this chapter and a plan of correction is requested of the inpatient psychiatric service provider by the department and is either not received within the time period specified by the department, is not granted approval by the department, or is not implemented by the inpatient psychiatric service provider;

(2) An inpatient psychiatric service provider's submitted application materials are not approved by the department;

(3) An inpatient psychiatric service provider ceases provision of inpatient services;

(4) An inpatient psychiatric service provider presents or submits false or misleading information as part of a license application, renewal, or investigation;

(5) An inpatient psychiatric service provider has been cited for a pattern of serious noncompliance or repeated violations of statutes or rules during the period of current or previous licenses;

(6) An inpatient psychiatric service provider does not apply for licensure renewal at least thirty days prior to the expiration date of the license; or

(7) The applicant, or any owner, sponsor, medical director, administrator, or principal of the applicant, is or has been the subject of an adverse action as defined in section 5119.334 of the Revised Code unless:

(a) A minimum period of three years has passed from the date of the adverse action; and

(b) The adverse action was not due to any act or omission that violated the patient's right to be free from abuse, neglect, or exploitation.

(C) Notice of the department's intent to deny or revoke a license is to be provided to the inpatient psychiatric service provider in accordance with section 119.07 of the Revised Code. An opportunity for a hearing is to be afforded the inpatient psychiatric service provider in accordance with Chapter 119. of the Revised Code.

(D) The submission of incomplete materials for the application is to be considered a failure to submit an application for licensure, and the non-issuance of an initial license or a renewal license due to an incomplete application is not to be considered the denial or revocation of a license.

(E) In proceedings initiated to deny, refuse to renew, or revoke licenses, the department may deny, refuse to renew, or revoke a license regardless of whether some or all of the deficiencies that prompted the proceedings have been corrected at the time of the hearing.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 10/12/1978, 7/1/2011

Rule 5122-14-06 | Waivers and variances.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) An inpatient psychiatric service provider may submit a dated, written request to the department for a waiver or variance. The written request is to clearly state the licensure rule of the waiver/variance request, the rationale and need for the requested waiver or variance, and the consequence of not receiving approval of the request.

(B) Upon receipt of a written request for a waiver or variance that provides a clear and valid statement of need, the department in its discretion may grant a waiver or variance for a period of time determined by the department but that is not to exceed the expiration date of the current license.

(C) The department will acknowledge and respond to the waiver/variance request within thirty days of receipt by the department.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/1991, 1/1/2000, 7/1/2011

Rule 5122-14-07 | Display of license.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) The current license is to be displayed by the inpatient psychiatric service provider in a conspicuous place that is readily accessible to the patients and the public.

(B) The license is to remain the property of the department; revoked or terminated licenses are to be returned to the department.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/1991, 7/1/2011

Rule 5122-14-08 | Fee schedule.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) The purpose of this rule is to state the fees for various classifications of license.

(B) The provisions of this rule applies to each inpatient psychiatric service provider licensed by the department.

(C) Definitions applying to this rule are those appearing in rule 5122-14-01 of the Administrative Code.

(D) An inpatient psychiatric service provider is to pay an annual fee with each application for full licensure or full licensure renewal according to the following schedule:

Psychiatric bed capacity	Fee
25 or less persons	$750
26-50 persons	$1350
51-75 persons	$1650
76-100 persons	$1950
Over 100 persons	$2250

(E) Fees for probationary and interim licenses or re-issuance of a license due to a change in the number of licensed beds may be assessed and will be prorated based on the annual fee.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 10/12/1978, 1/1/1991, 1/1/2000

Rule 5122-14-10 | Patient safety and physical plant requirements.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) Each inpatient psychiatric service provider is to comply with all applicable TJC, ACHC, or DNV mandates and federal, state, and local laws and regulations regarding patient care, safety, sanitation, and fire protection.

(1) A building inspection is to be made upon application for an initial license and repeated whenever renovations or changes in the building are made that would affect either the maximum number of licensed patient beds or substantially change the services provided by the inpatient psychiatric service provider, as well as when the department deems a building inspection is necessary.

(2) If an inpatient psychiatric service provider occupies part of a building, the entire building is to be inspected except where there is a fire wall or other fire resistant separation between the part of the building to be licensed and the rest of the building. If this fire separation does not exist the total building is to be used to determine safety for inspection purposes only.

(3) A building inspection is to be performed by a local certified building inspector or, where none is available, by the chief of the bureau of building code compliance in the Ohio department of commerce.

(4) The inpatient psychiatric service provider is to be inspected annually by a certified fire authority or, where none is available, by the division of state fire marshal in the Ohio department of commerce. Copies of annual inspections are to be maintained by the inpatient psychiatric service provider for a period of at least three years or until the next on-site licensure survey.

(5) The inpatient psychiatric service provider's food service is to be inspected annually by the authorized local municipal county health department. Copies of annual inspections are to be maintained by the inpatient psychiatric service provider for a period of at least three years or until the next on-site licensure survey.

(6) If the inpatient psychiatric service provider's water supply and sewage disposal is not part of a municipal system, it is to comply with applicable state or local regulations, rules, codes, or ordinances.

(B) Each inpatient psychiatric service provider is to provide an environment that is clean, safe, aesthetic, and therapeutic. Appropriate space, equipment, and facilities are to be available to provide services.

(1) If smoking is permitted, a separate, enclosed area is to be used for smoking;

(2) Each patient's sleeping room is to have all of the following:

(a) A window, with an operable covering for privacy, that has a view to the outdoors;

(b) A minimum of one hundred net square feet of usable floor space per bed for single occupancy, and a minimum of eighty net square feet of usable floor space per bed for multi-occupancy;

(c) A minimum of a bed, chair, storage for personal belongings, and other therapeutic furnishings as appropriate; and

(d) A degree of privacy from other patients if there is more than one bed in the room.

(3) Child/adolescent patients are not to share the same sleeping room with adult patients.

(4) For all patients, a safe and secure storage area for personal belongings accessible to the patient is to be provided. Personal belongings that may pose safety issues for patients may be placed in a safe and secure storage area accessible to patients through a request of staff.

(5) Each inpatient psychiatric service provider is to provide common patient areas that adequately meet patient needs and program mandates.

(a) There is to be a minimum of eighty total square feet of usable social space per licensed bed to include:

(i) A patient lounge area totaling at least thirty square feet per licensed bed, including separate smoking and non-smoking areas if smoking is permitted in the lounge area;

(ii) A patient activity area totaling at least thirty square feet per licensed bed which may include indoor recreation areas;

(iii) Dining room facilities to meet patient needs;

(iv) A patient kitchen area to include a sink, a refrigerator, and cooking facilities as appropriate to patient need; and

(v) A patient laundry area.

(6) Patient lounge, activity, and dining areas are to be shared spaces as appropriate to patient need. Child/adolescent patients are to be provided the use of a patient lounge area appropriate for their use separate from adult use of patient lounge areas.

(7) There are to be private areas to include all of the following:

(a) A private area for visitation from family members, significant others, or other persons;

(b) A private area for telephone use;

(c) A group therapy area as appropriate to patient need; and

(d) Private areas to include places and times for personal privacy.

(8) Each inpatient psychiatric service provider is to provide an environment that is accessible to persons with disabilities and make reasonable accommodations in accordance with all applicable federal, state and local laws and regulations.

(9) Each inpatient psychiatric service provider is to develop policies and procedures regarding services designed to assist deaf/hard of hearing persons as well as persons for whom English is not the primary language.

(a) Services are to be provided at such a level so that the patient and patient's family or significant others are not denied the benefits of participation in the inpatient psychiatric service provider's treatment program. Services will comply with all applicable state and federal guidelines regarding the maintenance of patient confidentiality. As applicable, such services are to consist of but are not to be limited to availability of all of the following:

(i) Qualified interpreters with demonstrated ability or certification;

(ii) Telecommunication devices for the deaf or hard of hearing; and

(iii) Television closed caption capability.

(b) Such services are to be available to patients and their family members or significant others who are receiving services. Specifically for emergency services, the inpatient psychiatric service provider is to have policies and procedures that address the need for immediate accessibility to qualified interpreters, telecommunication devices for the deaf/hard of hearing, and other assistance with communication.

(c) Direct care staff and treatment team members are to be trained in issues relating to barriers to traditional verbal/English communication.

(d) Services to assist patients and families of patients or significant others are to be available at no charge to the patient, family, or significant others.

(10) Each inpatient psychiatric service provider is to implement a falls prevention program that is monitored through its quality improvement process.

(C) Each inpatient psychiatric service provider is to have a sufficient number of professional, administrative, and support staff to meet both census needs and patient needs.

(1) Staffing for all services is to reflect the volume of patients, patient acuity, and the level of intensity of the services provided to ensure that desired outcomes of care are achieved and negative outcomes are avoided.

(2) Staffing of any organized patient activity (e.g., rehabilitation therapy services or nursing services provided to groups of patients) is to be sufficient to ensure safety and may be dependent on the type, duration, and location of the activity and the immediate accessibility of other staff.

(3) For nursing services:

(a) A 1:4 minimum nursing staff-to-patient ratio is to be maintained as an overall average in any four week period with the exception of night hours when patients are sleeping.

(b) For reasons of safety, at least two staff members are to be present at all times.

(c) A registered nurse is to be on site twenty-four hours each day, seven days a week.

(d) A registered nurse is to be available for direct patient care when needed.

(D) Each inpatient psychiatric service provider is to meet all applicable medicare conditions of participation (including 42 C.F.R. 482.13(e)), TJC, ACHC, or DNV standards for seclusion and restraint in addition to complying with all of the following provisions:

(1) The following are not to be used under any circumstances:

(a) Behavior management interventions that employ unpleasant or aversive stimuli such as the contingent loss of the regular meal, the contingent loss of bed, and the contingent use of unpleasant substances or stimuli such as bitter tastes, bad smells, splashing with cold water, and loud, annoying noises;

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

(c) Any technique that obstructs vision;

(d) Any technique that restricts the individual's ability to communicate;

(e) Any technique that causes an individual to be retraumatized based on an individuals history of traumatic experiences;

(f) Weapons and law enforcement restraint devices, as defined by CMS in appendix A of its interpretive guidelines to 42 C.F.R. 482.13(e) and found in " CMS State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals,"July 21, 2023, revision, used by any hospital staff or hospital-employed security or law enforcement personnel, as a means of subduing a patient to place that patient in patient restraint/seclusion; and

(g) Chemical restraint; and

(h) Prone restraint.

(2) Position in physical or mechanical restraint.

An individual is to be placed in a position that allows airway access and does not compromise respiration. Hospital staff are not authorized to utilize prone restraint.

(3) The inpatient psychiatric service provider is to identify, educate, and approve staff members to use seclusion or restraint. Competency of staff in the use and documentation of seclusion or restraint methods is to be routinely evaluated. The results of evaluations are to be maintained by the inpatient psychiatric service provider for a minimum of three years for each staff member identified.

Staff are to have appropriate training prior to utilizing seclusion or restraint, and, at a minimum, annually thereafter. The exception to annual training is a first aid or CPR training/certification program of a nationally recognized certifying body, e.g., the american red cross or american heart association, when that certifying body establishes a longer time frame for certification and renewal.

(a) Staff are to be trained in and demonstrate competency in the safe application of all seclusion or restraint interventions he or she is authorized to perform;

(b) Staff are to be trained in and demonstrate competency in choosing the least restrictive intervention based on an individualized assessment of the patient's behavioral and/or medical status or condition;

(c) Staff are to be trained in and demonstrate competency in recognizing and responding to signs of physical distress in clients who are being secluded or restrained;

(d) Staff are to be trained and certified in first aid and CPR;

(e) Staff are to be trained in and demonstrate competency in recognizing and responding to signs of physical distress in clients who are being secluded or restrained;

(f) Staff authorized to take vital signs and blood pressure are to be trained in and demonstrate competency in taking them and understanding their relevance to physical safety and distress;

(g) Staff are to be trained in and demonstrate competency in assessing circulation, range of motion, nutrition, hydration, hygiene, and toileting needs; and

(h) Staff are to be trained in and demonstrate competency in helping a client regain control to meet behavioral criteria to discontinue seclusion or restraint.

(4) The presence of advance directives or client preferences addressing the use of seclusion or restraint is to be determined and considered, as well as documented in the medical record. If the inpatient psychiatric service provider will be unable to utilize seclusion or restraint in a manner in accordance with the patient's directives or preferences, the provider is to notify the patient, give the rationale, and document such in the ICR

(5) In each patient's medical record, upon admission and upon any relevant changes in the patient's condition, any perceived medical or psychiatric contraindications for the possible use of seclusion or restraint is to be documented. The specific contraindication is to be described and is to take into account the following which may place the patient at greater risk for such use:

(a) Gender;

(b) Chronological and developmental age;

(c) Physical body size;

(d) Culture, race, ethnicity, and primary language;

(e) History of physical, sexual abuse, or psychological trauma;

(f) Medical and other conditions that might compromise physical well-being, e.g., asthma, epilepsy, obesity, lung and heart conditions, an existing broken bone, pregnancy, and drug/alcohol use;

(g) Physical disabilities; and

(h) Psychiatric condition.

(6) Orders are to be written only by an individual with specific clinical privileges/authorization to order seclusion and restraint, granted by the inpatient psychiatric service provider, and who is a:

(a) Psychiatrist or other physician; or

(b) Physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

Countersignatures to telephone orders for seclusion or restraint are to be signed within twenty-four hours by an individual with specific clinical privileges/authorization to order seclusion and restraint, granted by the hospital, and who is a psychiatrist or other physician, physician assistant, certified nurse practitioner, or clinical nurse specialist.

(7) Following the conclusion of each incident of seclusion or restraint, the patient and staff are to participate in a debriefing.

(a) The debriefing is to occur within twenty-four hours of the incident unless the client refuses, is unavailable, or there is a documented clinical contraindication.

(b) The following are to be invited to participate unless such participation is clinically contraindicated and the rationale is documented in the clinical record:

(i) For a child/adolescent client, the family, or custodian or guardian.

(ii) For an adult client, the client's family or significant other when the client has given consent, or an adult client's guardian, if applicable.

(8) As part of the inpatient psychiatric service provider's performance improvement process, a periodic review and analysis of the use of seclusion and restraint is to be performed.

(9) The inpatient psychiatric service provider is to maintain an ongoing log of its seclusion and restraint utilization for departmental review. A log is to be maintained for department review of each incident of mechanical restraint, seclusion, and physical restraint, and for time-out exceeding sixty minutes per episode. The log is to include, at minimum, the following information:

(a) The person's name or other identifier;

(b) The date, time, and type of method utilized, i.e., seclusion, physical restraint, mechanical restraint, or time-out. The log of physical and mechanical restraint is to also describe the type of intervention as follows:

(i) For mechanical restraint, the type of mechanical restraint device used;

(ii) For physical restraint, the type of hold or holds; and

(c) The duration of the method or methods.

If restraint is necessary as a means of safely transporting an individual to seclusion, either a separate order for restraint and a separate order for seclusion is needed or, alternatively, one order may be used that delineates a separate restraint and a separate seclusion.

If the restraint or seclusion episode is concluded, and the patient's behavior necessitates initiating another restraint or seclusion, then a new order needs to be obtained, even if the ending time of the original order has not passed.

(10) Plan to reduce seclusion and restraint.

(a) A inpatient psychiatric service provider that utilizes seclusion or restraint is to develop a plan designed to reduce its use. The plan is to include attention to the following strategies:

(i) Identification of the role of leadership;

(ii) Use of data to inform practice;

(iii) Workforce development;

(iv) Identification and implementation of prevention strategies;

(v) Identification of the role of clients (including children), families, and external advocates; and

(vi) Utilization of the post seclusion or restraint debriefing process.

(b) A written status report is to be prepared annually and reviewed by leadership.

(E) Pursuant to rule 5122-14-14 of the Administrative Code, the hospital is to notify the department of all of the following:

(1) Each instance of physical injury to a patient that is restraint-related, e.g., injuries incurred when being placed in seclusion and/or restraint or while in seclusion or restraint, with the exception of injury that is self-inflicted, i.e., a patient banging his/her own head;

(2) Each death that occurs while a person is restrained or in seclusion;

(3) Each death occurring within twenty four hours after the person has been removed from restraint or seclusion; and

(4) Each death where it is reasonable to assume that a person's death may be related to or is a result of such seclusion or restraint.

(F) Staff actions commonly known as therapeutic, supportive, or directional touch, utilized to direct an individual to another area without the use of force and which do not restrict an individual's freedom of movement, are not considered restraint and are not subject to the provisions of paragraph (D) of this rule.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 10/12/1978, 11/1/2005

Rule 5122-14-11 | Patient rights, participation and education.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) In addition to the definitions appearing in rule 5122-14-01 of the Administrative Code, the following definitions apply to this rule:

(1) "Patient rights specialist" means the individual designated by the inpatient psychiatric service provider with responsibility for assuring compliance with the patient rights and grievance procedure rule.

(2) "Grievance" means a written complaint initiated either verbally or in writing by a patient or by any other person or agency on behalf of a patient regarding denial or abuse of any patient's rights.

(3) "Reasonable" means a standard for what is fair and appropriate under usual and ordinary circumstances.

(4) "Services" means the complete array of professional interventions designed to help a person achieve improvements in mental health such as counseling, individual or group therapy, education, community psychiatric supportive treatment, assessment, diagnosis, treatment planning and goal setting, clinical review, psychopharmacology, discharge planning, professionally-led support, etc.

(B) Each patient has the following rights, as well as the additional rights listed in paragraph (C) of this rule:

(1) Regarding access to patient rights and financial information:

(a) The right to be informed within twenty-four hours of admission of the rights described in this rule and to request a written copy of these rights;

(b) The right to receive information in language and terms appropriate for the patient's understanding; and

(c) The right to request to speak to a financial counselor.

(2) Regarding personal liberty:

(a) In accordance with existing federal, state, and local laws and regulations, the right to be treated in a safe treatment environment, with respect for personal dignity, autonomy, and privacy;

(b) The right to receive services that are appropriate and respectful;

(c) The right to receive humane services;

(d) The right to participate in any appropriate and available service that is consistent with an individual service/treatment plan, regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation;

(e) The right to reasonable assistance, in the least restrictive setting; and

(f) The right to reasonable protection from physical, sexual, or emotional abuse or harassment.

(3) Regarding the development of service/treatment plans:

(a) The right to a current individualized treatment plan (ITP) that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, as available, either directly or by referral; and

(b) The right to actively participate in periodic ITP reviews with the staff including services necessary upon discharge.

(4) Regarding declining or consenting to services:

The right to give full informed consent to services prior to commencement and the right to decline services absent an emergency.

(5) Regarding restraint or seclusion:

The right to be free from restraint or seclusion unless there is imminent risk of physical harm to self or others.

(6) Regarding privacy:

(a) The right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non-hospital surveyors, contractors, construction crews, or others; and

(b) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies, or photographs, or other audio and visual recording technology. This right does not bar a hospital from using closed-circuit monitoring to observe seclusion rooms or common areas, but closed circuit monitoring is not to be utilized in patient bedrooms and bathrooms.

(7) Regarding confidentiality:

(a) The right to confidentiality unless a release or exchange of information is authorized and the right to request to restrict treatment information being shared; and

(b) The right to be informed of the circumstances under which the hospital is authorized or intends to release, or has released, confidential information without written consent for the purposes of continuity of care as permitted by division (A)(7) of section 5122.31 of the Revised Code.

(8) Regarding grievances:

The right to have the grievance procedure explained orally and in writing; the right to file a grievance with assistance if requested; and the right to have a grievance reviewed through the grievance process, including the right to appeal a decision.

(9) Regarding non-discrimination:

The right to receive services and participate in activities free of discrimination on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner not permitted by local, state or federal laws.

(10) Regarding reprisal for exercising rights:

The right to exercise rights without reprisal in any form including the ability to continue services with uncompromised access. No right extends so far as to supersede health and safety considerations.

(11) Regarding opinions:

The right to have the opportunity to consult with independent specialists or legal counsel, at one's own expense.

(12) Regarding conflicts of interest:

No inpatient psychiatric service provider employee may be a person's guardian or representative if the person is currently receiving services from said provider.

(13) The right to have access to one's own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual patient for clear treatment reasons in the patient's treatment plan. If access is restricted, the treatment plan is to also include a goal to remove the restriction.

(14) The right to be informed in advance of the reasons for discontinuance of service provision, and to be involved in planning for the consequences of that event.

(15) The right to receive an explanation of the reasons for denial of service.

(C) In addition to the rights listed in paragraph (D) of this rule, each consumer residing in an inpatient psychiatric hospital is to have the following rights and be informed of such rights:

(1) The right to receive humane services in a comfortable, welcoming, stable, and supportive environment.

(2) The right to retain personal property and possessions, including a reasonable sum of money, consistent with the person's health, safety, service/treatment plan, and developmental age.

(3) Regarding the development of service/treatment plans, the right to formulate advance directives, submit them to hospital staff, and rely on practitioners to follow them within the parameters of the law.

(4) Regarding labor of patients, the right to not be compelled to perform labor that involves the operation, support, or maintenance of the hospital or for which the hospital is under contract with an outside organization. Privileges or release from the hospital are not to be conditioned on the performance of such labor.

(5) Regarding declining or consenting to services:

(a) The right to consent to or refuse the provision of any individual personal care activity and/or mental health services/treatment interventions; and

(b) The right, when on voluntary admission status, to decline medication, unless there is imminent risk of physical harm to self or others; or

(c) The right when hospitalized by order of a probate or criminal court to decline medication after being given the opportunity to give informed consent, unless there is imminent risk of harm to self or others, or through an order by the committing court (e.g., persons admitted for a competency evaluation under division (G)(3) of section 2945.371 of the Revised Code or admitted for a sanity evaluation under division (G)(4) of section 2945.371 of the Revised Code).

(6) Regarding privacy, dignity, free exercise of worship, and social interaction:

The right to enjoy freedom of thought, conscience, and religion, including religious worship within the hospital and receipt of services or sacred texts that are within the reasonable capacity of the hospital to supply. However, no patient is to be coerced into engaging in any religious activities.

(7) Regarding private conversation and access to phone, mail, and visitors:

(a) The right to communicate freely with and be visited at reasonable times by the patient's family members, significant others, legal guardian, and private counsel or personnel of the legal rights service and, unless prior court restriction has been obtained, to communicate freely with and be visited at reasonable times by a personal physician or psychologist;

(b) The right to communicate freely with others, unless specifically restricted in the patient's service/treatment plan for reasons that advance the person's goals, including the following:

(i) The right of an adult to reasonable privacy and freedom to meet with visitors, guests, or surveyors, and make and/or receive phone calls; or the right of a minor to meet with inspectors, and the right to communicate with family, guardian, custodian, friends, and significant others outside the hospital in accordance with the minor's individualized service/treatment plan;

(ii) The right to have reasonable access to telephones to make and receive confidential calls, including a reasonable number of free calls if unable to pay for them and assistance in calling if requested and needed. The right of a minor to make phone calls is to be in accordance with the minor's individualized service/treatment plan.

(c) The right to have ready access to letter-writing materials, including a reasonable number of stamps without cost if unable to pay for them, and to mail and receive unopened correspondence and assistance in writing if requested and needed subject to the hospital's rules regarding contraband. The right of a minor to send or receive mail is also subject to directives from the minor's parent or legal custodian when such directives do not conflict with federal postal regulations.

(8) Notification to family or physician:

The right to have a physician, family member, or representative of the person's choice notified promptly upon admission to a hospital.

(D) Each inpatient psychiatric service provider is to provide a patient rights specialist to safeguard patient rights. The patient rights specialist or the specialist's designee is to meet all of the following criteria and fulfill all of the following responsibilities:

(1) Be appropriately trained and knowledgeable in the fundamental human, civil, constitutional, and statutory rights of psychiatric patients including the role of the Ohio protection and advocacy system (disability rights Ohio);

(2) Ensure that the patient, and as appropriate, the patient's family members, significant others, and legal guardian, are informed about patient rights, in understandable terms, upon admission, and throughout the hospital stay. Treatment staff are to work with the patient to assist them in understanding and exercising patient rights. For any person who is involuntarily detained, the inpatient psychiatric service provider will, immediately upon being taken into custody, inform the person orally and in writing of their rights described in division (C) of section 5122.05 of the Revised Code;

(3) Be accessible in person during normal business hours and during evenings, weekends, and holidays as needed for advocacy issues. The name, title, location, hours of availability, and telephone number of the patient rights specialist along with a copy of the patient rights and grievance procedure as set forth in this rule is to be posted in an area available to the patient and made available to the patient's legal guardian, if any, as well as the patient's family and significant others upon their request. In addition, the patient rights and grievance procedure as set forth in this rule, as well as the telephone number of the patient rights specialist, is to be posted on the provider's web site;

(4) Assist and support patients, their family members, and significant others in exercising their legal rights and representing themselves in resolving complaints. This is to include providing copies of the inpatient psychiatric service provider's policies and procedures relevant to patient rights and grievances upon request, and assistance with the grievance procedure. This is to also include assistance in obtaining services of the Ohio protection and advocacy system (disability rights Ohio) in accordance with sections 5123.60 and 5123.601 of the Revised Code, and assistance in obtaining access to or services of outside agencies or resources upon request;

(5) Not be a member of the patient's treatment team and not have clinical management or care responsibility for the patient for whom he or she is acting as the patient rights advocate; and

(6) Maintain a log available for department review of patient grievances, including all allegations of denial of patient rights as identified by patients, family members of patients, significant others or other persons.

(E) Each inpatient psychiatric service provider is to ensure that its staff members are knowledgeable about patient rights and referral of patients to the patient rights advocate.

(F) Each inpatient psychiatric service provider is to ensure that patients and families of patients participate in an advisory capacity related to programming and relevant policies and procedures.

(G) Each inpatient psychiatric service provider is to ensure that patient and family education is an interdisciplinary and coordinated process, as appropriate to the patient's treatment plan, consistent with patient confidentiality and documented in the medical record. Education is to incorporate appropriate members of the treatment team, types of materials, methods of teaching, community educational resources, as well as special devices, interpreters, or other aids to meet specialized needs.

(H) Each inpatient psychiatric service provider is to obtain the informed consent of a patient or when appropriate, a guardian, for all prescribed medications that have been ordered, except in an emergency, and for those medical interventions specified in division (A) of section 5122.271 of the Revised Code.

(1) Each inpatient psychiatric service provider is to ensure that the patient and legal guardian, when legally appropriate, receives written and/or oral information in a language and format that may be standardized and that is understandable to the person receiving it.

(a) Information is to include the anticipated benefits and side effects of the intervention, including the anticipated results of not receiving the intervention, and of alternatives to the intervention.

(b) Persons served are to be given the opportunity to ask questions, seek additional information, and provide input before the intervention or medication is administered or dispensed.

(c) Documentation is to be kept in the patient's medical record regarding the patient's participation in this process, including the patient's response, objections, and decisions regarding the medication or medical intervention. Such documentation may be accomplished through a notation from an appropriate professional staff person, signature of the patient or guardian, or other mechanism.

(2) For purposes of informed consent specific to medication, each psychiatric inpatient service provider is to ensure that the patient and parent or legal guardian when legally appropriate receives written and/or oral information from a physician, registered nurse, or pharmacist.

Last updated April 24, 2024 at 8:36 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/2000

Rule 5122-14-12 | Program, specialty services and discharge planning requirements.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) Each inpatient psychiatric service provider is to have a written comprehensive plan of service that will be reviewed annually and revised if necessary.

(B) The comprehensive plan of service is to include all of the following:

(1) A description of services provided;

(2) A description of any affiliation or agreements with other agencies or entities;

(3) A description of the population served including age groups and other relevant characteristics of the patient populations;

(4) Criteria for admission, continued stay, and discharge; and

(5) A description of how patients and family members of patients are to participate in an advisory role with respect to the inpatient service.

(C) Criteria for admission will:

(1) Limit admissions to those persons whose principal diagnosis and focus of treatment upon admission is a mental disorder according to the latest edition of the American psychiatric association's diagnostic and statistical manual of mental disorders (DSM), except that persons whose principal diagnosis and focus of treatment is a substance abuse disorder, detoxification for substance abuse, a chronic dementing organic mental disorder, or intellectual disability are to be excluded. This does not preclude admissions for which the above named excluded diagnoses may be a secondary diagnosis;

(a) To support best clinical practice of concurrent integrated treatment for persons with co-occurring of mental illness and substance abuse, an inpatient psychiatric service provider may co-locate both psychiatric and substance abuse and/or detox registered beds in the same physical area, and may use staff who are cross-trained in both treatment disciplines to provide integrated services.

(b) Until September 30, 2024, the total number of psychiatric beds and the total number of detox (medical/surgical) beds and/or substance abuse beds are to remain as registered with the Ohio department of health.

(c) Patients are to be admitted to the appropriate bed based upon their principal diagnosis and focus of treatment. However, this would not preclude integrated concurrent treatment for a co-occurring disorder.

(2) Include any applicable age limits, diagnostic categories, and other criteria necessary to ensure that each admission is the least restrictive alternative available and consistent with each patient's treatment needs;

(3) Specify procedures and timelines for responding to an application for voluntary admission; and

(4) Assure that the inpatient psychiatric service provider will accept patients on a civil commitment and that it has the clinical competence to treat these patients:

(a) Utilizing the same criteria applied to voluntary patients, and

(b) According to admission criteria applied to voluntary patients.

The inpatient psychiatric service provider is to assure that it will provide such patients access to its full range of available services.

(D) Discharge criteria is to include, but not be limited to, achievement of treatment goals, or that the patient is to be transferred to a more appropriate treatment facility. A civilly committed patient is to be discharged when the patient no longer meets the criteria for civil commitment, however such patients are to have the right to apply for voluntary admission status at any time pursuant to division (G) of section 5122.15 of the Revised Code.

(E) The primary function of each inpatient psychiatric service provider is to provide diagnostic and treatment services for persons with a primary diagnosis of mental illness. Such services are to be culturally relevant and sensitive and take into consideration any relevant patient history of trauma and/or abuse.

(F) Clinical services are to be provided by an interdisciplinary treatment team working together.

(1) All members of the treatment team who have specific treatment responsibilities are to have either appropriate clinical privileges and be qualified by training or experience and demonstrated competence or be supervised by a clinically privileged practitioner.

(2) Each inpatient psychiatric service provider is to specify in policy and procedures the roles and responsibilities of team members in identifying and meeting the clinical needs of patients in relationship to goals and programs.

(3) Each inpatient psychiatric service provider is to assure and provide for the staffing of team members to meet the clinical needs of each patient as identified in the patient's treatment plan.

(G) Each professional discipline will:

(1) Identify special skills needed to render specific patient care and treatment services.

(2) Participate in the development of criteria for qualifications of its staff members, which are to include education, experience, and licensure or certification mandates.

(H) Each inpatient psychiatric service provider is to provide or make provision for the services specified in this paragraph in order to promote recovery and meet the comprehensive needs of each patient. Such services may be provided by any qualified individual, unless otherwise specified in these rules and/or regulated by professional licensure and scope of practice.

(1) Medical services are to be:

(a) Under the direction of a psychiatrist; and

(b) Include availability of a psychiatrist for consultation twenty-four hours a day, seven days a week, either in person or by telephone.

Medical services, including dental, are to meet the comprehensive physical and psychiatric treatment needs of each patient as identified in the patient's treatment plan.

(2) Dietetic services, including availability of a licensed dietitian.

(3) Emergency services, which are to be available and accessible through a written plan for psychiatric emergencies for both persons receiving inpatient treatment from the inpatient psychiatric service provider and for any persons presenting themselves as in need of and requesting emergency treatment.

(a) If the inpatient psychiatric service provider maintains an emergency room or emergency service, it will not refuse emergency care to individuals presenting with potentially life or health-threatening psychiatric situations.

(b) If the inpatient psychiatric service provider does not maintain an emergency room or emergency service, it will provide emergency care on site until an individual presenting with a potentially life or health-threatening psychiatric situation is transferred to a more appropriate provider.

(4) Nursing services, which are to be under the direction or supervision of a full time registered nurse who has a bachelor's or master's degree in nursing and four years psychiatric nursing experience. It is preferred that the individual hold voluntary certification in psychiatric and mental health nursing by the American nurses credentialing association. This mandate applies to those individuals hired into this position after January 1, 2000.

Psychiatric nursing experience is the treatment and care of persons whose principal diagnosis and focus of treatment is a psychiatric disorder; the experience can include working as a registered nurse on a psychiatric inpatient unit or in an outpatient setting with individuals who have a primary psychiatric diagnosis. Psychiatric nursing experience does not include either of the following:

(a) Experience derived from caring for individuals in a nursing home, whose principal diagnosis is often a chronic dementing organic mental disorder; or

(b) For a nurse hired or after July 1, 2024, experience derived from working in a hospital medical unit, emergency department, or other healthcare setting where individuals do not have a primary psychiatric diagnosis.

(5) Pastoral services are to be offered by the inpatient psychiatric service provider's clergy or the provider is to arrange for pastoral services from family or community clergy;

(6) Patient education services are to be readily accessible at all reasonable hours and include current reading and resource materials for education and leisure to meet the needs of the patients;

(7) Pharmaceutical services are to meet both of the following mandates:

(a) Be under the direction of a pharmacist with a current license.

(b) Operate in accordance with Chapters 3715., 3719., and 4729. of the Revised Code regarding operation of pharmacies, storage, and dispensing of drugs;

(8) Physical rehabilitation services are to be under the direction of qualified staff;

(9) Psychological services are to be under the direction of a licensed psychologist;

(10) Psycho-social services are to meet all of the following mandates:

(a) Be provided by qualified staff;

(b) Be staffed by at least one person who is licensed either as a professional counselor, professional clinical counselor, independent social worker, or a social worker; and

(c) Be provided during the day, and available evenings, weekends, and holidays as needed.

(11) Rehabilitation therapy services are to meet all of the following mandates:

(a) Be provided by qualified staff;

(b) Be staffed by at least one rehabilitation therapist as defined in rule 5122-14-01 of the Administrative Code;

(c) Be provided during the day, and available evenings, weekends, and holidays as needed;

(d) Be provided by rehabilitation therapy staff with diverse skills to meet the needs of all patients; and

(12) Substance abuse diagnostic and treatment services for all patients who have a secondary problem of substance use disorder are to be provided by an individual licensed or certified by the Ohio chemical dependency professionals board under Chapter 4758. of the Revised Code or by an individual licensed or certified by the counselor, social worker, and marriage and family therapist board under Chapter 4757. of the Revised Code whose scope of practice includes the diagnosis and treatment of substance use disorders.

(I) Each inpatient psychiatric service provider is to develop special programs to include, but not be limited to, the following groups whenever the annual average daily census for that group is six or more patients:

(1) Adults age sixty-five and older;

(2) Patients with a secondary diagnosis of substance use disorder; and

(3) Patients with a secondary diagnosis of developmental disability or pervasive developmental disorder.

(J) Written policies and procedures and program descriptions are to document that patient needs, based on at least age and diagnosis, will be met for all patient groups in paragraph (I) of this rule.

(1) Inpatient psychiatric service providers that provide services for adults sixty-five years of age and older are to develop written policies and procedures regarding services to meet the special needs of such patients. These needs include vision, hearing, dietary, physical, cognitive, functional living skills and psychiatric needs, and the needs of the patients' family members. Special attention is to be given to problems associated with utilization of medication including polypharmacy. Diagnostic and treatment services are to be provided by a psychiatrist with clinical privileges in geriatric psychiatry. Consultation with an occupational therapist or an occupational therapy assistant in collaboration with an occupational therapist are to be available as appropriate to each patient's needs.

(2) Services for patients who have a secondary problem of substance abuse are to include specialized diagnostic assessments, group and/or individual therapy, education, linkage to self help groups, and referrals for post discharge substance abuse treatment, if appropriate.

(3) Inpatient psychiatric service providers that provide services for patients with a secondary diagnosis of intellectual disability or developmental disability are to adhere to treatment standards in accordance with Chapters 5122. and 5123. of the Revised Code or equivalent standards and as appropriate to the psychiatric services provided.

(K) Inpatient psychiatric service providers authorized to serve children and adolescents are to provide for the educational, recreational, developmental, social, and functional needs of these patients and for the treatment needs of these patients' families.

(1) For all children twelve years of age or less, diagnostic and treatment services are to be provided by a child and adolescent psychiatrist, or by a psychiatrist in consultation with a child and adolescent psychiatrist within seventy-two hours of admission.

(2) For all children thirteen through seventeen years of age, diagnostic and treatment services are to be provided by a child and adolescent psychiatrist, a psychiatrist with clinical privileges in adolescent psychiatry, or by a psychiatrist in consultation with a child and adolescent psychiatrist within seventy-two hours of admission.

(3) Each inpatient psychiatric service provider is to provide rehabilitation therapy services to each patient as appropriate to the patient's needs and as indicated in the patient's treatment plan, including at least five hours per week of active physical activities.

(4) Each inpatient psychiatric service provider is to provide a a patient with at least two hours per week of family therapy or other family interventions as appropriate to patient need and indicated on the patient's treatment plan.

(5) Each inpatient psychiatric service provider is to provide a patient with at least five hours per week of services intended to assist the patient in maintaining his/her educational and intellectual development, consistent with the patient's treatment plan.

(a) If the admission is longer than ten days, the inpatient psychiatric service provider with the consent of the parent/adult student is to notify the school district where the provider is located of the need for services and provide appropriate physical space so that the patient can access or continue individualized education plan IEP services provided by the school district.

(b) If educational needs and/or eligibility for special education services under Chapter 3323. of the Revised Code are identified during the admission, the inpatient psychiatric service provider is to communicate this to the patient's home school upon parent or guardian request with appropriate consent.

(L) If a psychiatric intensive care unit is provided the following additional standards are to be met:

(1) The psychiatric intensive care unit is to be directed and staffed according to the special needs of its patients;

(2) Written policies and procedures are to describe criteria for the use of psychiatric intensive care and any special procedures used; and

(3) Psychiatric intensive care units are to be designed and equipped to facilitate safe and effective care of patients.

(M) Inpatient psychiatric service providers that accept individuals into an observation or treatment status for periods of less than twenty-four hours are to develop policies and procedures regarding all of the following:

(1) Conditions under which individuals are accepted and released;

(2) The provision of patient rights information; and

(3) The provision of after hospitalization care.

(N) Prior to or within twenty-fours hours of admission of each patient, appropriate community resources and needs relative to the patient's treatment are to be identified. These community resources and needs may include or pertain to professionals who have rendered prior treatment to the patient, referral sources, courts, schools, employers, religious affiliation, community psychiatric supportive treatment services, and discharge planning.

(O) All identified community resources, when appropriate to patient need and with permission of the patient, are to be contacted to participate in treatment planning for discharge. Such efforts and involvement will be documented in the medical record.

(P) If a patient is likely to be referred to a community mental health agency upon discharge, the inpatient psychiatric service provider with permission from the patient is to invite participation by the community psychiatric supportive treatment providers from the local community mental health agencies in team meetings and planning for discharge.

(Q) The inpatient psychiatric service provider is to make arrangements for each patient for post discharge services as specified in the patient's treatment plan.

(1) Each inpatient psychiatric service provider is to provide an appropriate discharge plan for patients, or the inpatient psychiatric service provider is to arrange for each of these patients, as necessary, to receive mental health services from other mental health providers, consistent with patient choice and acceptance.

(a) The inpatient psychiatric service provider is to provide interim post discharge services for up to two weeks post discharge, unless the post discharge provider assumes responsibility for the provision of mental health services prior to the end of the interim two-week period. This is to include an appointment for medication management as needed. Such interim post discharge services are to include a crisis management plan, which may include a mechanism to contact a physician, interim medication management, referral to or provision of a support group or individual supportive services, or a mechanism to contact an emergency services provider.

(b) The inpatient psychiatric service provider is to determine, in collaboration with the patient and post discharge provider, that the post discharge provider has the appropriate services the patient has been identified as needing, including the provision of in-depth patient education regarding the nature and management of the patient's illness/disorder.

(2) As part of discharge planning and prior to discharge, the inpatient psychiatric service provider is to make all reasonable efforts to ensure that the patient has an appointment, as appropriate, with one or more mental health service providers not later than two weeks post discharge if it has been concluded that these services are mandated within two weeks.

(3) For children/adolescents, each inpatient psychiatric service provider is to make provision for coordination of psycho-educational treatment and recommended aftercare with the patient's local school and any existing individualized education plan from the patient's local school.

(4) The clinical treatment team is to develop a discharge plan with active participation by the patient. The parent, guardian, or family is also to participate, where appropriate, according to the treatment plan and, if needed, with permission of the patient. If the patient is a minor in the custody of an agency, that agency is to participate in the development of the discharge plan.

(5) A copy of the relevant portions of the post discharge plan is to be given to the patient, or as appropriate, the patient's guardian, and is to be made available, with the patient's permission, to the person or agency that will assume primary responsibility for implementation of the discharge plan.

(R) When utilization patterns indicate problems or opportunities for improvement in the larger community system in which the inpatient psychiatric service provider is located, the inpatient psychiatric service provider is to discuss these issues with the relevant boards of alcohol, drug addiction, and mental health services. Such discussions are to be documented.

Last updated April 24, 2024 at 8:37 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/1991, 1/1/2000, 2/17/2017

Rule 5122-14-13 | Medical records, documentation and confidentiality.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) Each inpatient psychiatric service provider is to maintain a complete medical record for each individual patient.

(B) A medical record is to include all of the following:

(1) Patient demographic information, including indication of legal status as a voluntary or involuntary patient;

(2) All legal documents, including, as appropriate, an application for voluntary admission signed and dated by the patient, written requests for release pursuant to section 5122.03 of the Revised Code, and all legal documents pertaining to civil commitment and guardianship.

For patients with a guardian, the inpatient psychiatric service provider is to make an effort to obtain all needed consent forms signed and dated by the guardian. If the guardian is unable to provide written consent, the provider may obtain and document verbal consent of the guardian as long as two individuals document, in writing, that each witnessed the guardian provide the verbal consent.

(3) The reason for admission including presenting problems, precipitating factors, and initial diagnosis;

(4) Previous hospitalizations;

(5) Reports of all patient assessments and examinations;

(6) An individualized treatment plan that includes criteria for discharge and meets mandates in section 5122.27 of the Revised Code;

(7) All medical orders;

(8) Documentation of the patient's progress and other significant patient events that could impact treatment;

(9) Appropriate, complete, signed, and dated consents for treatment and release of confidential information;

(10) A discharge summary completed within thirty days after discharge and signed by the attending or treating physician; and

(11) A post discharge plan.

(C) All entries in the medical record are to be dated, signed, and legible.

(D) Each inpatient psychiatric service provider is to be responsible for conducting a complete assessment of each patient including a consideration of the patient's strengths and needs and the types of services to meet those needs in the least restrictive environment consistent with treatment needs.

(1) The assessments are to include, as appropriate to patient need: physical, laboratory, emotional, behavioral, social, recreational, cognitive, functional living skills, educational, legal, vocational, nutritional, cultural, religious, income support, housing needs, and other community support and discharge planning needs.

(2) Each inpatient psychiatric service provider is to define in writing the scope of assessments to be performed by each clinical discipline not otherwise specified in this chapter, consistent with the discipline's scope of practice, state licensure laws, applicable regulations, certification, or registration.

(E) Written assessments of each patient are to be provided and dated by the respective interdisciplinary team members as soon as possible after admission and prior to the development of the treatment plan mandated within twenty-four hours of admission unless otherwise specified in this rule.

(1) For new admissions if assessments are available from prior evaluations and/or admissions within the past six months, each assessment is to be reviewed, revised as necessary, dated, and signed by a member of the respective discipline as soon as possible after admission and prior to the development of the treatment plan.

(2) The following mandated patient assessments are to be completed within twenty-four hours of a patient's admission:

(a) A medical history and physical examination is to be completed by a physician. If the patient's condition does not permit completion of the examination, each part of the examination is to be completed as soon as the patient's condition permits it. If a physician was responsible for the completion of a medical history and physical examination within thirty days of the current course of treatment and the patient's condition remains consistent with the results of that examination, a signed copy of this history and examination may suffice. The medical history and physical examination may be conducted by a physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

(i) The history and physical examination is to include a basic neurological examination that includes an examination of the cranial nerves, sensory and motor functions, coordination, and deep tendon reflexes.

(ii) If the patient is a child, adolescent, or person with an intellectual or developmental disability, the history and physical examination is to include evaluations of motor development and functioning, sensorimotor functioning, speech, hearing and language functioning, visual functioning, immunization status, and oral health and oral hygiene.

(b) A psychiatric examination, including mental status examination, is to be competed by a psychiatrist or a physician with specific clinical privileges to conduct such an examination. Alternatively, the psychiatric examination may be conducted by a physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

(c) An assessment of each patient's nursing care needs to be completed by a registered nurse. As part of the nursing assessment, the registered nurse is to conduct a screening of each patient's nutritional status unless otherwise assessed by a registered dietitian.

(d) An assessment for functional and rehabilitation needs is to be completed. The assessment may include an evaluation of the patient's activities of daily living; community living skills; social, leisure and vocational skills; self care and self control abilities; physical/sensori-motor capabilities; speech, language, oral, and pharyngeal sensor-motor competencies; and auditory and vestibular competencies.

(e) An emotional and behavioral assessment. The assessment is to include an evaluation of the patient's history of emotional, behavioral, substance-abuse problems or treatment, and physical or sexual abuse.

(f) A psycho-social assessment. The assessment is to include the following information about the patient, as appropriate:

(i) Environment and home;

(ii) Leisure and recreation;

(iii) Work history;

(iv) Spirituality;

(v) Childhood history;

(vi) Military service history;

(vii) Financial status;

(viii) Usual social, peer-group, and environmental setting;

(ix) Sexual orientation; and

(x) Family circumstances, including the constellation of the family group, the current living situation, and social, ethnic, cultural, emotional, and health factors. The psychosocial assessment includes determining the need and extent for family participation.

(g) In programs serving children and adolescents, an assessment is to be performed that includes an evaluation of all of the following:

(i) The impact of the child's or adolescent's condition on the family and the family's impact on the child or adolescent;

(ii) The child's or adolescent's legal custody status, when applicable;

(iii) The child or adolescent's growth and development, including physical, emotional, cognitive, educational, nutritional, and social development;

(iv) The child's or adolescent's play and daily activities needs; and

(v) The family's or guardian's expectations for and involvement in the child's or adolescent's assessment, initial treatment, and continuing care.

(F) Each patient is to have a written individualized treatment plan that is responsive and timely to the treatment needs of the patient based on information provided by the patient and the patient's family and assessments by the clinical treatment team. The initial treatment plan and subsequent revisions are to be developed with the active participation of the patient, and through collaborative efforts of the clinical team. As appropriate and with patient consent, family members and significant others are also to participate. Such patient, family, and clinical treatment team collaboration is to be documented in the treatment plan. A patient's inability or refusal to participate in treatment planning and the patient's reasons for such are to also be documented in the treatment plan. The patient, and as appropriate parent or guardian, is to have the right to be informed of changes in the treatment plan including a change in assignment of the primary therapist or attending physician.

(1) The initial treatment plan is to be developed with the active participation of the patient and implemented within twenty-four hours of admission through collaborative efforts by the interdisciplinary clinical treatment team.

(2) The initial treatment plan and any subsequent revisions to the plan are to do all of the following:

(a) Reflect the patient's clinical needs, condition, functional strengths, and limitations.

(i) The patient's perceptions of his or her needs are documented, as are the families' perceptions when appropriate and available.

(ii) Justification is documented when identified needs are not addressed;

(b) Specify goals for achieving emotional and/or physical health as well as maximum growth and adaptive capabilities.

(i) Treatment plan goals are based on assessments of the patient and, as appropriate, the family.

(ii) Treatment plan goals are linked to living, learning, and work activities.

(iii) Treatment goals identified by the patient and actions the patient agrees to or requests to take, and the patient's involvement in and expressed concerns about the treatment plan are documented;

(c) Specify intermediate steps toward those goals in measurable terms;

(d) Specify target dates or time-frames for completion of goals and steps;

(e) Specify services and interventions to be provided to achieve patient goals and indicate the staff persons and/or discipline responsible for provision of services;

(f) Specify frequency of services; and

(g) Specify criteria for discharge.

(3) The initial treatment plan is to be reviewed, updated, and/or revised within seventy-two hours of a patient's admission. All subsequent updates to the plan are to occur at least every seven days for the first month of hospitalization, at least monthly thereafter, and as appropriate to patient needs.

(G) The discharge summary completed within thirty days after discharge is to include all of the following:

(1) An assessment of the patient's condition on admission;

(2) An assessment of the patient's condition upon discharge and reason for discharge;

(3) A description of diagnostic and treatment services received by the patient, with reference to interventions identified on the treatment plan, and the patient's response;

(4) All recommendations made to the patient;

(5) Medications prescribed upon discharge; and

(6) Initial and final diagnosis, both physical and psychiatric, according to the American psychiatric association's latest edition of the diagnostic and statistical manual of mental disorders (DSM), which is to be recorded in full without the use of either symbols or abbreviations.

(H) A discharge plan is to be developed with each patient and is to do all of the following:

(1) State all appropriate recommendations and specific plans to include, but not be limited to, psychiatric, medical, case management, housing, vocational, financial, educational needs, other community support needs, and community resources available to meet these needs;

(2) Identify specific resources and state recommendations for continued, ongoing patient and family education regarding the nature and management of the patient's illness or disorder;

(3) Specify persons or agencies responsible for each recommended intervention or service;

(4) Specify the time frame for initiation of each recommended intervention or service;

(5) Specify a crisis management plan as described in paragraph (Q)(1)(a) of rule 5122-14-12 of the Administrative Code; and

(6) Be signed and dated by the patient, or as appropriate parent or guardian, and by each member(s) of the clinical treatment team responsible for reviewing the plan with the patient. A patient's inability or refusal to sign or participate in discharge planning and the patient's reasons for such is to be documented in the plan.

(I) The patient's treatment plan and medical record are to be available to the patient and family members in accordance with section 5122.31 of the Revised Code.

(J) The inpatient psychiatric service provider is to have written policies and procedures regarding the release of information and confidentiality of oral or written patient information in compliance with section 5122.31 of the Revised Code.

Last updated April 24, 2024 at 8:37 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 2/17/2017

Rule 5122-14-14 | Incident notification and risk management.

• Effective: April 24, 2024
• Promulgated Under: 119.03

(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also mandates the agency to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.

(B) Definitions

(1) "Incident" means an event that poses a danger to the health and safety of patients and/or staff and visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the hospital.

(2) "Reportable incident" means an incident that needs to be submitted to the department, including incidents that are then to be forwarded by the department to disability rights Ohio. As referenced in division (E) of section 5119.36 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident."

(3) "Six month reportable incident" means an incident type of which limited information is to be reported to the department. A six month reportable incident is not the same as a reportable incident.

(4) "Six month incident data report" means a data report that is to be submitted to the department.

(C) The inpatient psychiatric service provider is to develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to patients, staff, and visitors. The inpatient psychiatric service provider is to identify in policy other incidents to be reviewed and analyzed.

(1) An incident report is to be submitted in written form to the inpatient psychiatric service provider's chief executive officer or designee within twenty-four hours of discovery of the incident.

(2) As part of the inpatient psychiatric service provider's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in policy, is to be performed.

(3) The inpatient psychiatric service provider is to maintain an ongoing log of its reportable incidents for departmental review.

(D) Any person who has knowledge of an instance of abuse or neglect of a child or adolescent, or alleged or suspected abuse or neglect of a child or adolescent, or of an alleged crime committed against a child or adolescent that would constitute a felony is to immediately notify the appropriate public children's services agency or law enforcement authorities in accordance with section 2151.421 of the Revised Code.

Even if the person has knowledge of an alleged crime against a child or adolescent committed by another child or adolescent, the person is to immediately notify law enforcement authorities.

(E) Any person who has knowledge of an instance of abuse or neglect of an elderly person, or alleged or suspected abuse or neglect of an elderly person, or of an alleged crime committed against an elderly person that would constitute a felony is to immediately notify the appropriate law enforcement and county department of job and family services authorities in accordance with section 5101.63 of the Revised Code.

(F) Each inpatient psychiatric service provider is to submit reportable incidents and six month reportable incidents as defined by and in accordance with the schedule included in appendix A to this rule.

(G) Each reportable incident is to be reported electronically through the web enabled incident reporting system (WEIRS) as mandated by the department, and is to be forwarded to the department within twenty-four hours of its discovery, exclusive of weekends and holidays. The WEIRS form is to include identifying information about the inpatient psychiatric service provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations specified in 45 C.F.R. 164.514(b)(2).

(1) The inpatient psychiatric service provider is to file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved patients, staff, and visitors.

(2) The inpatient psychiatric service provider is to notify the patient's parent, guardian, or custodian, if applicable, within twenty-four hours of discovery of a reportable incident and document such notification.

(a) Notification may be made by phone, mailing, faxing or e-mailing a copy of the incident form, or other means according to inpatient psychiatric service provider policy and procedures.

(b) When notification does not include sending a copy of the incident form, the inpatient psychiatric service provider is to inform the parent, guardian, or custodian, of his or her right to receive a copy and forward a copy within twenty-four hours of receiving a request for a copy. The inpatient psychiatric service provider is to document compliance with the provisions of this paragraph.

(H) Each inpatient psychiatric service provider is to submit a six month incident data report to the department utilizing the form in WEIRS.

The six month data report is to be submitted according to the following schedule:

(1) The six month data report for the period of January first to June thirtieth of each year is to be submitted no later than July thirty-first of the same year; and

(2) The six month data report for the period of July first to December thirty-first of each year is to be submitted no later than January thirty-first of the following year.

(I) The department may initiate follow-up and further investigation of a reportable incident or six month reportable incident as deemed necessary and appropriate, or may request such follow-up and investigation by the inpatient psychiatric service provider and/or regulatory or enforcement authority.

Last updated April 24, 2024 at 8:37 AM

Supplemental Information

Authorized By: R.C. 5119.33
Amplifies: R.C. 5119.33
Five Year Review Date: 4/24/2029
Prior Effective Dates: 1/1/2000, 11/1/2005, 2/17/2017