The purpose of this chapter is to state the requirements for written policies and procedures for providers that provide addiction treatment or mental health services and activities.
Chapter 5122-26 | Policies and Procedures for the Operation of Mental Health Services Agencies
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Rule 5122-26-02 | Applicability.
(A) The provisions of the rules contained in this chapter are applicable to each provider: (1) Providing mental health and addiction services that are funded by, or funding is being sought from: (a) The Ohio medicaid program for community mental health or community addiction services. (b) A board of alcohol, drug addiction, and mental health services. (c) Federal or department block grant funding for certified services. Any service contact provided by a provider that is paid for by the Ohio medicaid program for community mental health or community addiction services, or in whole or in part by any community mental health board of alcohol, drug addiction, and mental health service or federal or department block grant funding shall be subject to the provisions of this chapter. (2) Subject to department certification as a driver intervention program according to section 5119.38 of the Revised Code. (3) That voluntarily request certification. (B) These rules do not diminish or enhance the authority of community mental health boards of alcohol, drug addiction, and mental health services to administer the community mental health or addiction treatment system pursuant to the Ohio Revised Code, and applicable federal law. Supplemental Information |
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Rule 5122-26-03 | Governing body and governance.
(A) Each provider shall have a leadership structure. The leadership structure shall identify who is responsible for: (1) Governance; (2) Provider administration, i.e. planning, management and operational activities; and, (3) Provision of services. (B) Each corporation for non-profit shall have a governing body. For the purposes of this rule, governing body shall have the same meaning as governing board. The governing body shall guide, plan and support the achievement of the provider's mission, vision and goals. The governing body shall develop written by-laws, a code of regulation, or policies for the following: (1) Selection of members of the governing body. The composition of the governing body shall reflect the demographics of the community it serves; (2) Provisions for orienting new members of the board of directors; (3) The number of members of the governing body needed for a quorum; (4) Terms of office for the members of the governing body; and, (5) Provisions guarding against the development of, and prohibiting the existence of, a conflict of interest between a governing body member and the provider. (C) The governing body shall: (1) Provide for orientation of its new members, including providing information about governing structure, duties, responsibilities and operations of the organization; (2) Provide financial oversight and approve the annual budget and plan for services; (3) Conduct meetings of the governing body at least quarterly, which shall include: (a) Review an annual summary of quality assurance and risk management activities and document governing body actions taken as a result of this review; (b) Approve the quality assurance plan; (c) Review an annual summary of client rights activities and document governing body actions taken as a result of this review. (4) Maintain minutes of meetings of the governing body including, but not limited to: (a) Date, time and place of the meeting; (b) Names of members who attended; and (c) Topics discussed and actions taken. (5) Establish procedures for selecting the chief executive officer, executive director or equivalent; (6) Establish duties and responsibilities of the executive director; (7) Select the executive director; (8) Conduct an annual review and evaluation of the executive director; (9) Identify responsibility for leadership in the absence of the executive director; (10) Establish, review and update as necessary the provider's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the provider's national accrediting body, if applicable, or a minimum of every five years; (11) Ensure adequate malpractice and liability insurance protection for its corporate membership, governing body, advisory board if applicable, provider and provider staff, and review such protection annually; (12) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of certified services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other provider bodies, to: (a) Persons who are receiving or have received certified services, and their family members; and (b) Persons who collectively represent a wide range of community interests and demographic characteristics of the service district in categories such as race, ethnicity, primary spoken language, gender and socio-economic status; (13) Ensure that the hours of operation for services and activities accommodate the needs of persons served, their families and significant others; and, (14) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations. (D) A government provider shall identify its governance structure for the purpose of meeting the requirements of this rule. Each provider which is not a corporation for non-profit and therefore not subject to the provisions of paragraphs (B) and (C) of this rule shall have a written description of its governance structure, and identify whether the owner shall assume sole responsibility for the activities required in this rule, or whether the provider is governed by a governing body, board of directors, or other governance body. Provider governance shall: (1) Provide financial oversight and develop an annual budget and plan for services; (2) At least annually: (a) Review a summary of quality assurance and risk management activities and document governing body actions taken as a result of this review; and (b) Approve the annual quality assurance plan; and, (c) Review client rights activities and document governing body actions taken as a result of this review; (3) Establish duties and responsibilities of the executive director, chief executive officer or equivalent; (4) Select the executive director; (5) Conduct an annual review and evaluation of the executive director; (6) Identify responsibility for leadership in the absence of the executive director; (7) Establish, review and update as necessary the provider's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the provider's national accrediting body, if applicable, or a minimum of every five years; (8) Ensure adequate malpractice and liability insurance protection for its corporate membership, advisory board if applicable, provider and provider staff, and review such protection annually; (9) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of mental health and addiction services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other provider bodies, to (a) Persons who are receiving or have received mental health and addiction services, and their family members; and (b) Persons who collectively represent a wide range of community interests and demographic characteristics of the surrounding community, such as race, ethnicity, primary spoken language, gender, and socio-economic status; (10) Ensure that the hours of operation for services and activities accommodate the needs of persons served, their families and significant others; and (11) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations. (E) Each provider shall maintain a written table of organization or organization chart which documents the lines of responsibility of: (1) Governing body, if applicable; (2) Executive director; (3) Administrative leadership; and (4) Clinical oversight. Supplemental Information |
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Rule 5122-26-04 | Policy and procedure manual.
(A) Each provider shall develop a written manual of policies and procedures regarding all services and activities of the provider. (B) The policy and procedure manual shall be available for review by staff, persons served and their family and significant others. Supplemental Information |
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Rule 5122-26-06 | Human resources management.
(A) The purpose of this rule is to establish that the provider's human resource management processes shall assure the provider is able to provide quality, client-driven treatment services in a safe, respectful environment. (B) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definition shall apply to this rule: "Personnel" means any paid or unpaid person, volunteer, contract worker, student intern or other person who is a part of an provider's workforce, including but not limited to those who perform management, clinical, operations, clerical, or other functions in support of the provider's mission, vision and goals. Contract worker does not include an individual or company with whom the provider contracts to perform occasional maintenance such as lawn care, snow removal, painting, etc. Staff or employee shall have the same meaning as personnel. (C) The provider's human resources management policies, procedures and processes shall assure: (1) Development of a workforce comprised of competent, qualified staff, including clinical and non-clinical staff. (2) Appropriate and adequate supervision. (3) Continuing education. (4) Maintaining appropriate documentation. (D) The provider shall develop a job description for each position that includes: (1) Minimum qualifications for the position: (a) Competencies, e.g. knowledge, skills and experience. (b) Credentials and academic requirements, if applicable. Credentials includes individuals providing services which requires being credentialed by an Ohio credentialing board and/or a federal agency, e.g. a healthcare prescriber's DEA registration. (2) Duties and responsibilities of the position. (E) The provider shall verify credentials, when required, prior to hire and on an on-going basis. The provider may maintain documentation of verifying credentials by making a copy of the individual's license, certificate, registration or certificate, maintaining a log noting the date and name of person who verified credentials, or by a similar method. (F) Services to children and adolescents. Provider agencies offering services to children and adolescents shall assure: (1) Each employee utilized in positions which are responsible for the direct care or supervision of children or adolescents shall be at least eighteen years of age. (2) Any prospective employee, volunteer or student intern shall not have pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by a provider if the conditions as provided in paragraph (H) of rule 5101:2-5-09 of the Administrative Code have been met. (3) Criminal record background checks on employees, volunteers and student interns are conducted by the bureau of criminal identification and investigation (BCII), or any other state or federal agency designated by the director, and, if the prospective employee does not demonstrate that they have been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI). (G) The provider shall provide orientation training to staff and document the orientation training, which shall be completed within thirty calendar days of the first date of employment. Orientation shall include at a minimum the following: (1) Employee and client safety. (2) Provider's mission, vision and goals. (3) Characteristics of the population served. (4) Sensitivity to cultural diversity. (5) Policies and procedures specific to job duties and responsibilities. (6) Confidentiality, including HIPAA, and, if applicable 42 CFR part 2. (7) Reporting abuse and neglect policies and procedures. (8) Client rights and grievance policies and procedures. (H) Services and supervision. (1) All personnel for whom a state or federal credential is required by law or regulation shall maintain the current credential issued by the appropriate body in the state of Ohio and/or federal agency, and shall practice only within the scope of their credential. (2) Services requiring supervision in accordance with Chapter 5122-29 of the Administrative Code shall be under the supervision of an individual who is eligible to supervise services as set forth in rule 5122-29-30 of the Administrative Code, and who has demonstrated experience, competency, and education in the area supervised, i.e. substance abuse, mental health or dual diagnosis. (3) Each non-supervisor staff providing direct services shall receive regularly scheduled and documented supervision appropriate to their skill level, experience and job duties, and in accordance with the requirements of their license, certificate or registration, if applicable. Supervision may be provided in individual and group sessions, including supervisor participation in treatment plan meetings. (I) Continuing education and training. (1) The provider shall assure direct service and supervisory staff participate in continuing education and training. (a) Minimum training hours shall be in accordance with each individual's credentialing board, or (b) Staff providing or supervising services for which no credential issued by a state credentialing board is required shall complete at least twenty hours of continuing education every two years, based on the individual's date of hire. If the individual was originally hired in a position in which he/she was not required to participate in staff development training, but was later hired in such a position, the first twenty hours of training shall be completed within two years of the first date of work in the new position. Staff employed as of the effective date of this rule providing or supervising services for which no credential issued by a state credentialing board is required shall complete the required training within three years of the effective date, and every two years thereafter, based upon the hire date or first date of work in the new position, as applicable. (2) Training shall: (a) Maintain or increase competency; (b) Include topics specific to population served; and (c) Ensure culturally competent provision of service. (J) Performance evaluation. (1) The provide shall evaluate staff performance at a frequency required by its accrediting body, if applicable, or for a provider without behavioral health accreditation, annually. (2) The provider shall establish in writing a system and frequency for evaluating volunteers, based on job duties, scope of responsibility, and frequency of service. (3) The provider shall evaluate contract staff performance in accordance with its human resources management policies and procedures. (K) Personnel files. The provider shall maintain a personnel file for each employee, including contract staff and volunteers. Personnel files shall be stored in such a manner as to maintain the privacy of each staff person. Provider policies shall describe who shall have access to the various information contained within the file. Personnel files shall include the following: (1) All staff, including contract staff, student interns and volunteers: (a) Identifying information; (b) Verification of credentials, as applicable: (i) From professional regulatory boards in Ohio and federal agencies, if applicable, including either electronic verification or copies of current professional licenses, certifications, or registration; or (ii) Documentation of competency for individuals providing direct services or supervising services for which no credential is required. Each provider shall establish the documentation necessary to verify competency. (c) Position description. For contract staff, a copy of the contract containing duties, expectations and required qualifications is sufficient. (d) For providers which provide alcohol and other drug services, documentation that the employee has reviewed and agreed to abide by the federal regulations on the confidentiality of alcohol and drug abuse patient records (Title 42, Code of Federal Regulations, part 2). (e) Documentation of orientation, including documentation to reflect that the employee has received a copy of the policies and procedures identified in paragraph (G) of this rule and has agreed to abide by each of them. (f) The criminal background check required by paragraph (F) of this rule for all staff of an agency providing services to children and adolescents. (g) Disciplinary actions, if applicable. (2) All staff, excluding student interns or volunteers: (a) Notification of hire, to include start date and position. (b) For contract staff, a copy of the contract is sufficient. (3) All staff, excluding contract staff, student interns and volunteers: (a) Application for employment or resume, with the exception of the executive director, CEO, president or owner. (b) Verification of references, if required for position. (c) Performance evaluations. (d) Documentation of on-going training in accordance with paragraph (H) of this rule for staff who provide direct service or staff who supervise services. (L) The provider shall develop written human resources management policies and procedures sufficient to carry out the provisions of this rule. Policies and procedures shall include at a minimum: (1) Prohibit discrimination in employment, training, job duties, compensation, evaluation, promotion, and any other term or condition of employment based on 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 prohibited by local, state or federal laws; (2) Describe a formal process to express and process employee grievances; (3) Prohibit sexual harassment; (4) Establish standards of acceptable behavioral for all employees. (5) Termination of employment. (6) Confidentiality, including HIPAA, and, if applicable 42 CFR part 2 if applicable. (7) Abuse and neglect policies and procedures: (a) Required internal and external reporting of allegations of staff neglect and abuse of persons served. (b) Responding to allegations of staff neglect and abuse of persons served. (8) Client rights and grievance policies and procedures as required by rule 5122-26-18 of the Administrative Code. (9) Policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee's position. (10) Procedures for notifying employees of changes to the policies and procedures required by this rule. (M) A copy of the written personnel policies and procedures shall be available to each employee. Employees shall be notified of changes in personnel policies and procedures. (N) Each provider serving children or adolescents shall have a policy which states the following: (1) Each employee utilized in positions which are responsible for the direct care or supervision of children or adolescents shall be at least eighteen years of age. (2) A prospective employee, volunteer or student intern shall not have pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by a provider if the conditions as provided in paragraph (H) of rule 5102:2-5-09 of the Administrative Code have been met. (3) The provider shall require that criminal records checks on employees, volunteers and student interns be conducted by the bureau of criminal identification and investigation (BCII), or any other state or federal agency designated by the director, and, if the prospective employee does not demonstrate that they have been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI). (O) A copy of the written personnel policies and procedures shall be available to each employee. Employees shall be notified of changes in personnel policies and procedures. The provider shall establish written procedures for notifying employees of such changes. (P) Personnel files. (1) The provider shall maintain a person file on each staff person, who shall have access to their own personnel file. (2) Personnel files shall be stored in such a manner as to maintain the privacy of each staff person. Provider policies shall describe who shall have access to the various information contained within the file. (3) Each personnel file shall include the following content: (a) Identifying information and emergency contacts; (b) Application for employment or resume; (c) Verification of credentials from professional regulatory boards in Ohio, if applicable, including either electronic verifications or copies of current professional licenses, certifications, or registration; (d) Documentation of education, experience and training; (e) Verification of references, if required for position; (f) Notification of hire, to include start date and position; (g) Job or position description, to include job title and: (i) Supervisor to whom the person holding this position is responsible. (ii) Duties or responsibilities. (iii) Minimum qualifications for the position (knowledge and skills). (iv) Credentials and academic requirements, if applicable. (v) Positions supervised by person holding this position, if applicable (h) Compensation documentation, if applicable; (i) For providers which provide alcohol and other drug services, documentation that the employee has reviewed and agreed to abide by the federal regulations on the confidentiality of alcohol and drug abuse patient records (Title 42, Code of Federal Regulations, part 2). (j) Performance evaluations; (k) Documentation of orientation; (l) Documentation to reflect that the employee has received a copy of the policies and procedures identified in paragraph (D)(7) of this rule and has agreed to abide by each of them; (m) Documentation of on-going training, as required by position, state law and agency policy; (n) Commendations or awards, if applicable; and (o) Disciplinary actions, if applicable. (Q) The provider shall have policies and written procedures for handling cases of staff neglect and abuse of persons served, and documentation that each employee has received a copy of these policies and procedures. (R) The provider shall have a policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee's position. Supplemental Information |
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Rule 5122-26-08 | Confidentiality.
(A) This rule describes the minimum written policies and procedures for maintaining confidentiality in accordance with applicable federal and state laws and regulations; including, but not limited to, 42 C.F.R. part 2, confidentiality of alcohol and drug abuse client records, and the Health Insurance Portability and Accountability Act of 1996. (B) A provider staff person's access to an individual client's records, treatment information, diagnosis or other protected information is limited to access and disclosure in accordance with applicable federal and state laws and regulations. (C) Storage of client records shall be in accordance with all applicable federal and state laws and regulations. Supplemental Information |
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Rule 5122-26-08.1 | Security of clinical records systems.
(A) Each provider shall have policies and procedures addressing the security of its clinical records system. (B) If a provider maintains electronic health records (EHRs) it must be a system or module that is certified in accordance with the Public Health Service Act (PHSA) Title XXX and also comply with section 3701.75 of the Revised Code. The provider must be able to produce paper copies of client records upon legally valid requests. (C) Policies and procedures for providers maintaining a computer-based clinical records system shall include consideration of the following components: (1) Authentication - providing assurance regarding the identity of a user and corroboration that the source of data is as claimed; (2) Authorization - the granting of rights to allow each user to access only the functions, information, and privileges required by their duties; (3) Integrity - ensuring that information is changed only in a specific and authorized manner. Data, program, system and network integrity are all relevant to consideration of computer and system security; (4) Audit trails - creating immediately and concurrently with user actions a chronological record of activities occurring in the system: (5) Disaster recovery - the process for restoring any loss of data in the event of fire, vandalism, disaster, or system failure; (6) Data storage and transmission - physically locating, maintaining and exchanging data; and (7) Electronic signatures - a code consisting of a combination of letters, numbers, characters, or symbols that is adopted or executed by an individual as that individual's electronic signature; a computer-generated signature code created for an individual; or an electronic image of an individual's handwritten signature created by using a pen computer. Client record systems utilizing electronic signatures shall comply with section 3701.75 of the Revised Code. Supplemental Information |
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Rule 5122-26-09 | Provider service plan.
(A) The purpose of this rule is to ensure that the provider plans and develops services to meet the needs of the population served. (B) The provider shall define in writing its mission, vision and goals. (C) The provider shall develop a written description of each service provided, which shall include: (1) The description of the service, including services provided under each level of care, if applicable; (2) Schedule of the days the service is available, and hours of operation; (3) Needs and characteristics of the population served; (4) Goals and scope of service; and, (5) Description of services which are offered through referral or affiliations with other providers, and the responsibilities of each provider. (D) The provider shall revise and update the service description when any of the information required in paragraph (C) of this rule changes. (E) The provider service plan shall be available for review by persons served, their family, significant others and the public. Supplemental Information |
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Rule 5122-26-11 | Continuity of care agreements.
Each provider designated by the board to screen, refer, or admit persons to a state-operated psychiatric hospital shall have a signed continuity of care agreement describing the roles and responsibilities of the board, hospital, agency and department. Supplemental Information |
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Rule 5122-26-12 | Environment of care and safety.
(A) The purpose of this rule is to ensure that each agency maintains a clean, safe, appropriate environment which supports the provision of quality certified services and minimizes the risk of harm to clients, staff, visitors, and others. (B) Each provider shall designate the personnel who are responsible for implementing and oversight of the provisions of this rule. The personnel may be designated as an individual, position, or committee. (C) Each provider shall develop written policies and procedures to address emergency situations, including: (1) Fire, including the requirement that fire exit doors shall remain unlocked and clearly marked unless a variance has been granted by a certified authority of the division of state fire marshal of the department of commerce; (2) Bomb threat; (3) Natural disaster; (4) Utility outage or malfunction, e.g. a gas leak; and (5) Other potential threats which may be applicable based upon location, e.g. nuclear power plant leak. (D) Each provider shall have posted evacuation plans, conduct emergency drills and evaluate the effectiveness of the drill to ascertain the need for performance improvement: (1) Fire drills shall be conducted at least once every twelve months at each provider location offering services on a less than twenty-four hour/day basis. Residential and withdrawal management substance use disorder service providers shall conduct fire drills at least quarterly. A driver intervention program location is exempt from the provisions of this paragraph unless other services or programs are also available at the location. (2) The provider shall evaluate and determine the need to conduct other drills, and the frequency. This shall be included in its policies and procedures. (E) Each provider shall have written policies and procedure, which incorporate any applicable local, state or federal laws for: (1) Safe handling, storage and disposal of hazardous materials. (2) Safe handling and disposal of infectious waste materials, including applicable specifications of the occupational health and safety administration and the Ohio department of health. (3) Infection control, including applicable specifications of the occupational health and safety administration and the Ohio department of health. (4) Prohibiting the use of unvented kerosene, gas or oil heaters. (5) Hazardous areas of the provider. (F) The provider shall identify in its policies and procedures the need for initial and on-going training on each emergency or safety procedure, and the frequency of such training, and which staff/positions shall be required to receive each training. (G) Each provider shall meet local, state and federal laws regarding accessibility Whenever it identifies a structural or other barrier which limits access to or within the building, the provider shall develop a plan to remove the barrier. (H) The provider shall conduct regular safety inspections at least every six months, or more often as identified by the provider's policies and procedure or its accrediting body. Inspections shall include attention to: (1) Physical structure; (2) Electrical systems; (3) Heating and cooling systems; (4) Warning devices, e.g. exit lights, alarm systems, etc.; (5) Fire and carbon monoxide detection systems; (6) Fire suppression equipment; (7) Lighting; (8) Food preparation areas, if applicable; and (9) Any other areas or systems as needed and identified in provider policies and procedures. Driver intervention programs provided at motels, hotels, or camps are exempt from the inspection requirements of this paragraph. (I) Each provider shall ensure it obtains inspections and permits in accordance with local, state or federal laws. (1) At a minimum, the provider shall obtain the following inspections every twelve months: (a) Approved fire inspection, which shall be free of deficiencies, by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce, to include testing of fire alarm systems. (b) Water supply and sewage disposal inspection for facilities in which these systems are not connected with public services to certify compliance with rules of the department of health and any other state or local regulations, rules, codes or ordinances. (2) The provider shall ensure that it obtains inspections and maintains current permits as required by law, if applicable for the following: (a) Elevator inspection. (b) Boiler inspection. (c) Food service. (d) Swimming pool. (e) Any other as required by local, state or federal law. Driver intervention programs provided at motels, hotels, or camps are exempt from the inspection requirements of this paragraph. (J) For a client assessed in need of a specialized diet, the provider shall maintain written documentation that the planning and preparation of meals is done so in accordance with a plan and instructions prepared by a physician or a dietitian licensed by the state medical board of Ohio. Supplemental Information |
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Rule 5122-26-13 | Incident notification and risk management.
(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires the provider 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) "County community board of residence" means the board that is responsible for referring or paying for the client's treatment. (2) "County community board" means a board with which the provider has entered into a contract to provide services or facilities. (3) "Incident" means an event that poses a danger to the health and safety of clients or staff and visitors of the provider, and is not consistent with routine care of persons served or routine operation of the provider. (4) "Reportable Incident" means an incident that must be submitted to the department. As referenced in division (E) of section 5119.36 of the Revised Code, "Major Unusual Incident" has the same meaning as "Reportable Incident." (5) "Six month reportable incident" means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident. (6) "Six month incident data report" means a data report which must be submitted to the department. (C) The provider shall 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 clients, staff, and visitors. The provider shall identify in policy other incidents to be reviewed and analyzed. (1) An incident report shall be submitted in written form to the provider's executive director or designee within twenty-four hours of discovery of a reportable incident. (2) As part of the provider's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in the provider's policy, shall be performed. This shall include a review of all incident reports received from class two and class three residential facilities as defined in division (B) of section 5119.34 of the Revised Code regarding persons served by the provider, and any action taken by the provider, as appropriate. (3) The provider shall maintain an ongoing log of its reportable incidents for departmental review. (D) Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of: (1) Any child or adolescent, shall immediately notify the county children's services board, the designated child protective agency, or law enforcement authorities, in accordance with section 2151.421 of the Revised Code; or (2) An adult age sixty and over, shall immediately notify the appropriate county department of jobs and family services authorities in accordance with section 5101.63 of the Revised Code. (E) Each provider shall submit reportable incidents and six month reportable incidents as defined by and according to the schedule included in appendix A to this rule. (F) Each reportable incident shall be documented as required by the department. The information shall include identifying information about the provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [45 C.F.R. 164.514(b)(2)], and 42 CFR Part B, paragraph 2.22., if applicable. (1) The provider shall file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved clients, staff, and visitors. If, after submitting a reportable incident to the department, a provider learns that an additional incident report category in addition to that which was already submitted is associated with the same event occurrence, the provider shall either amend the original report or submit a new incident report including only the new incident category and information. (2) The provider shall forward each reportable incident to the department and to the county community board of residence within twenty-four hours of its discovery, exclusive of weekends and holidays. (G) Each provider shall submit a six month incident data report to the department and to the county community board utilizing the form that is in appendix B to this rule. The six month incident data report must be submitted according to the following schedule: (1) The six month incident data report for the period of January first through June thirtieth of each year shall be submitted no later than July thirty-first of the same year; and (2) The six month incident data report for the period of July first through December thirty-first of each year shall be submitted no later than January thirty-first of the following year. (H) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the provider, regulatory or enforcement authority, or the county community board. Supplemental Information |
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Rule 5122-26-14 | Provider closing or acquisition.
(A) If a provider certified by the department voluntarily closes, it shall give a thirty-day advance written notice to each of its current clients which specifies the date that the program will close. If a client is a minor, the program shall send notice to the minor client's parent or legal guardian, and to the minor in accordance with section 3719.012 of the Revised Code. (1) A copy of this notice shall be placed in each client's clinical record. (2) A copy of this notice shall be sent to the: (a) Department's legal and regulatory service office responsible for compliance and certification of agencies. (b) The boards for the counties in which the provider offers services. (3) A program close-out audit shall be conducted which shall meet the department's guidelines and federal office of management and budget circulars. (B) If a client will require ongoing services after the projected closing date, the provider shall: (1) Refer the client to another provider certified by the department or to an individual in private practice who is qualified to provide the services needed; and, (2) Have documentation to ascertain that the provider or private practice has accepted the client for admission. A progress note by a case manager or clinician stating the date, time and place that the client is scheduled for an intake interview will meet the requirements of this standard. (C) If a program discontinues operations or is taken over or acquired by another entity, it shall comply with division (A)(15) of section 5119.28 of the Revised Code and 42 C.F.R., part 2, subsection 2.19 which govern the disposition of records by discontinued programs. Supplemental Information |
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Rule 5122-26-15 | Medication handling and drug theft.
(A) The provider shall have written policies and procedures regarding the purchasing, receipt, storage, distribution, return, and destruction of medication that include accountability for and security of prescription and over-the-counter medications located within any of its facilities. These policies and procedures shall include, but not be limited to the requirements that providers handling medications shall: (1) Hold a valid and current terminal distributor of dangerous drugs license from the Ohio board of pharmacy if maintaining a stock supply of prescription medications, if participating with the department's central pharmacy to receive dispensed prescriptions, or when otherwise required by rules of the Ohio board of pharmacy. (2) Locate all medications and prescription blanks in a locked, secure area; (3) Designate a person having access to or authorized to handle medications and shall maintain a current list of these persons, their credentials and their medication handling responsibilities. (4) Provide a method to record and follow the medications from the time of receipt to the time of distribution, return to central pharmacy, or destruction. This record shall be retained by the provider for three years and shall include, but not be limited to the following information: (a) The date and time the medication was received by the provider, distributed to persons served, returned to central pharmacy or, if appropriate, destroyed; (b) The name, credentials and signature of all persons handling medications; and (c) The provision that unused medications prescribed for a person shall be appropriately destroyed or returned to central pharmacy, and that, under no circumstances shall the unused medications be issued to another individual. Return of unused medications prescribed to a person is only allowed when the return is to central pharmacy in accordance with rule 4729-9-04 of the Administrative Code. (5) Ensure that all staff handling medications have basic and ongoing instruction and training in safe and effective handling of medications. (6) Ensure that medications are handled only by authorized persons and that others do not have access to the medications; and (7) Ensure that controlled substances may be destroyed only by an agent of the Ohio board of pharmacy, or the federal drug enforcement agency, or by transfer to persons registered under Chapters 3719. and 4729. of the Revised Code and according to rule 4729-9-06 of the Administrative Code. (B) Providers maintaining a limited stock supply of medications shall: (1) Allow only a physician or pharmacist to dispense medications, although the following individuals may personally furnish samples of some medications if issued a certificate to prescribe: (a) Certified nurse practitioner and clinical nurse specialist in accordance with division (D) of section 4723.481 of the Revised Code; and (b) Physician's assistant in accordance with division (A) of section 4730.43 of the Revised Code. (2) Have visibly posted the phone number of the nearest poison control center. (C) Each provider that permits clients to self-administer medication shall have written policies and procedures that include, but are not limited to, the following: (1) Procedures for storing medications in a locked and secured cabinet, or similar storage. (2) Procedures for self-medication. (3) Procedures for accounting for medications that are kept for the client while they are at the program site. (4) Each provider shall describe in its policies and procedures whether clients are permitted to self-administer medication at the provider site, and whether clients are permitted to have unsecured prescription and over-the-counter medication in their possession while at the client site. When clients are not permitted to have medication in their possession, the provider shall have written procedures for obtaining, accounting for, and returning medication at the time of departure or discharge. (D) The provider shall have a policy on employee medication theft and shall inform all employees concerning this policy. The policy shall include attention to prescription as well as over-the-counter medications maintained for client use. (1) An employee, intern or volunteer with knowledge of medication theft by an employee or any other person shall report such information to the executive director of the provider. If the executive director of the provider is suspected of medication theft, the employee or volunteer shall notify the department. The provider shall take all reasonable steps to protect the confidentiality of the information and the identity of the person furnishing the information. (2) Suspected medication theft shall be reported to the Ohio board of pharmacy. For controlled substances, suspected medication theft shall also be reported to the federal drug enforcement administration. Providers participating in medication services with the Ohio department of mental health and addiction services central pharmacy shall also notify central pharmacy. (3) Failure to report information of medication theft shall be considered in determining the eligibility of the employee to continue to work in a secure area where medications are stored. (4) If an employee violates the provider's medication theft policies, the provider shall assess the seriousness of the employee's violation, whether the violation has a direct and substantial relationship to that employee's position, the past record of employment, and other relevant factors in determining whether to suspend, transfer, terminate, or take other action against the employee. Supplemental Information |
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Rule 5122-26-16 | Seclusion, restraint and time-out.
(A) This rule is applicable to all certified providers and licensed class one residential providers. The purpose of this rule is to state the general standards applicable to the use of seclusion, mechanical restraint, or physical restraint. The provisions of this rule and rule 5122-26-16.1 of the Administrative Code are not applicable to forensic restrictions imposed by correction and law enforcement authorities for security (non-clinical care) purposes. The use of restraint or seclusion by correction, law enforcement or other staff for the purposes of clinical care is subject to the provisions of this rule. A provider which prohibits the use of seclusion and restraint will develop a policy stating such. (B) The provision of a physically and psychologically safe environment is a basic foundation and requirement for effective mental health and addiction services treatment. Adopting trauma informed treatment practices, creating calm surroundings and establishing positive, trusting relationships are essential to facilitating a person's treatment and recovery. The goal of reducing and minimizing the use of seclusion and restraint is one that will be shared and articulated by the provider's leadership. The elevation of oversight by leadership of each use of seclusion or restraint in order to investigate causality, ascertain relevancy of current policies and procedures, and identify any associated workforce development issues, is core to the successful achievement of this goal. Seclusion and restraint are intrusive techniques to be used by trained, qualified staff as a last resort in order to control dangerous and potentially harmful behaviors and to preserve safety. Best practices include careful early assessment of a person's history, experiences, preferences, and the effectiveness or ineffectiveness of past exposure to these methods. Best practices will be based on understanding and consideration of the individual's history of traumatic experiences as a means to gain insight into origins and patterns of the individual's actions. Use of seclusion or restraint will be subject to performance improvement processes in order to identify ways in which the use of these methods can be decreased or avoided and more positive, relevant and less potentially dangerous techniques used in their place. When individuals experience repeated or sustained use of these methods, leadership should evaluate all causative factors and consider alternative treatment interventions and possible transfer to or placement in a more structured treatment setting with the capacity to meet individual needs with reduced exposure to these intrusive interventions. (C) The following definitions apply to rules 5122-26-16 to 5122-26-16.1 of the Administrative Code and are in addition to those contained in rule 5122-24-01 of the Administrative Code: (1) "Advance directives" means a legal document used by an adult to direct in advance the mental or physical health treatment in the event the adult lacks the capacity to make such decisions. Two types of advance directives related to mental health treatment are: a "Declaration for Mental Health Treatment" subject to the requirements of Chapter 2135. of the Revised Code, and a "Durable Power of Attorney for Health Care" subject to the requirements of sections 1337.11 to 1337.17 of the Revised Code. (2) "Behavior management" means the utilization of interventions that are applied in a systematic and contingent manner in the context of individual or group programs to change or manage behavior or facilitate improved self-control. The goal of behavior management is not to curtail or circumvent an individual's rights or human dignity, but rather to support the individual's recovery and increase the individual's ability to exercise those rights. (3) "Comfort rooms," (formerly known as quiet or time-out rooms), are adapted sensory rooms that provide sanctuary from stress or can be places for persons to experience feelings within acceptable boundaries. (4) "Individual crisis plan" means a written plan that allows the person to identify coping techniques and share with staff what is helpful in assisting to regain control of the person's behavior in the early stages of a crisis situation. It may also be referred to as a "behavior support plan." (5) "Mechanical restraint" means any method of restricting a person's freedom of movement, physical activity, or normal use of his or her body, using an appliance or device manufactured for this purpose. (6) "Physical restraint", also known as "manual restraint," means any method of physically restricting a person's freedom of movement, physical activity, or normal use of the person's body without the use of mechanical restraint devices. Transitional holds are not physical restraint. (7) "PRN (pro re nata)" means as the situation demands. (8) "Prone Restraint" means all items or measures used to limit or control the movement or normal functioning of any portion, or all, of an individual's body while the individual is in a face-down position. Prone restraint may include either physical (also known as manual) or mechanical restraint. (9) "Qualified person" means an employee or volunteer who carries out the agency's tasks under the agency's administration and/or supervision, and who is qualified to utilize or participate in the utilization of seclusion or restraint by virtue of the following: education, training, experience, competence, registration, certification, or applicable licensure, law, or regulation. (10) "Seclusion" means the involuntary confinement of a person alone in a room where the person is physically prevented from leaving. (11) "Sensory rooms" means appealing physical spaces painted with soft colors with the availability of furnishings and objects that promote relaxation and/or stimulation. (12) "Time-out" means an intervention in which staff compel a person to remove themself from regular programming to a specified place for a specified period of time. Time-outs are allowed in areas away from activity, which may include time out rooms, other identified space in the facility, or the client's bedroom. Time-out is not seclusion or restraint. (13) "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, mechanical, or physical restraint as defined in this rule. Transitional holds are not seclusion or restraint. (D) Policies and procedures (1) The provider will establish policies and procedures that reflect the provisions of this rule and rule 5122-26-16.1 of the Administrative Code. The provider will document if and how the inclusion of clients and families in the development of such policies occurred. (2) Policies and procedures governing the use of seclusion or restraint will include attention to preservation of the person's health, safety, rights, dignity, and well-being during use. Additionally: (a) Respect for the person will be maintained when such methods are utilized; (b) Use of the environment, including the possible addition of comfort, soothing and sensory rooms, will be designed to assist in the person's development of emotional self-management skills; and, (c) The number of appropriately trained staff available to apply or initiate seclusion or restraint will be adequate to ensure safety. The use of non-agency employed law enforcement personnel, e.g., local law enforcement, to substitute for the lack of sufficient numbers of appropriately trained staff in such situations is prohibited. (3) Policies and procedures will include the mailing address and toll-free phone number of disability rights Ohio. (E) General requirements (1) Seclusion or restraint will not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is identified. (a) Seclusion and restraint will not be used as behavior management interventions, to compensate for the lack of sufficient staff, as a substitute for treatment, or as an act of punishment or retaliation. (b) Absent a co-existing crisis situation that includes the imminent risk of physical harm to the individual or others, the destruction of property by an individual, in and of itself is not adequate grounds for the utilization of seclusion or restraint. (2) The following will not 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 restricts the individual's ability to communicate, including consideration given to the communication needs of individuals who are deaf or hard of hearing; (c) Any technique that obstructs vision; (d) Any technique that causes an individual to be retraumatized based on an individual's history of traumatic experiences; (e) Any technique that obstructs the airways or impairs breathing; (f) Use of mechanical restraint on individuals under age eighteen; (g) A medication that is used as a restraint to control behavior or restrict the individual's freedom of movement and is not a standard treatment or dosage for the individual's medical or psychiatric condition or that reduces the individual's ability to effectively or appropriately interact with the world around the individual; (h) The use of handcuffs or weapons such as pepper spray, mace, nightsticks, or electronic restraint devices such as stun guns and tasers, other than the use of handcuffs or other devices used by corrections and law enforcement personnel for security purposes; The presence of weaponry in an agency poses potential hazards, both physical and psychological, to clients, staff and visitors. Utilization by the agency of non-agency employed armed law enforcement personnel (e.g., local police) to respond to and control psychiatric crisis situations, will be minimized to the extent possible; and (i) Prone restraint. (3) Seclusion and restraint will be utilized in a manner that is safe, proportionate, and appropriate to the severity of the behavior. (4) The choice of the least restrictive, safe and effective use of seclusion or restraint for an individual is determined by the person's assessed needs, including a consideration of any relevant history of trauma or abuse, risk factors as identified in paragraph (H)(3) of this rule, the effective or ineffective methods previously used with the person and, when possible, upon the person's preference. (5) Each person will be informed of the agency's philosophy on the use of seclusion or restraint as well as of the presence of any agency policies and procedures addressing their use by the agency. This disclosure will occur upon admission or intake unless it is not clinically warranted; however the person will be provided the disclosure as soon as clinically warranted. The person's parent, custodian, or guardian will be provided these disclosures at admission or intake. This explanation will be in a language that the client and their parent, custodian or guardian understand, including American sign language if appropriate. A copy of the policies and procedures will be provided in writing to the person and to their parent, custodian or guardian when applicable . The agency will maintain written acknowledgment from the client or from their parent, custodian or guardian that they have been informed of the agency's policies and procedures on seclusion or restraint. (a) Adult clients will be offered the opportunity to give consent for the notification of their use to a family member or significant other. (b) For minor clients, the agency will obtain contact information in order to notify the parent, custodian or guardian. The agency may allow the parent, custodian or guardian to specify certain hours during which they do not want to be notified. (6) The inclusion of clients (including children), families, and external advocates in various roles and at all provider levels to assist in reducing the use of seclusion or restraint will be considered. (F) Staff training. The provisions of this paragraph are applicable to all staff whose normal duties are to interact with those persons served by the provider and any other staff involved in the use of seclusion and restraint. Staff will be trained and demonstrate competency before participating in any seclusion or restraint intervention. (1) The agency will mandate staff to have ongoing education and training. Staff training will include training exercises in which staff members successfully demonstrate in practice the techniques they have learned for managing emergency situations. Staff will have training in and demonstrated knowledge of: (a) Techniques to identify staff and individual behaviors, events, and environmental factors that may trigger seclusion or restraint. (b) The use of nonphysical intervention skills, such as de-escalation, mediation conflict resolution, active listening, and verbal and observational methods, as alternatives to the use of seclusion and restraint. (c) The safe use of restraint and seclusion (d) The ability to recognize and respond to signs of physical distress in individuals who are restrained or in seclusion, including attention to vitals, and certification in cardiopulmonary resuscitation and first aid. After initial certification, staff will be recertified either according to the time frame of a national first aid certifying body, e,g, the American red cross, or annually. (e) Recognize signs of distress in youth to help reduce the use of seclusion and restraint through the use of trauma assessments, detection of early warning signs, and the development of calming/soothing plans and other strategies to help youth self-regulate. The calming/soothing plans will be documented in the individualized treatment plan. (2) Individuals providing staff training will: (a) Be qualified to do so by education, training, and experience. (b) Document that staff received training and demonstrated competency. This will occur before staff participate in any seclusion or restraint intervention, and on an on-going basis: (i) Staff will be certified and recertified in cardiopulmonary resuscitation. Staff certified by programs approved by the American red cross or the American heart association will be recertified in accordance with time frames established by the certifying entity. (ii) Staff will be certified and recertified in first aid. Staff certified by programs approved by the American red cross or the American heart association will be recertified in accordance with time frames established by these entities. Staff certification under other programs will be recertified at least once every twelve months unless a longer time frame is approved by the department. (iii) Non psychiatric residential treatment facility (PRTF) staff will demonstrate all other competencies as in paragraph (F)(1) of this rule at least once every twelve months. PRTF staff will demonstrate competencies as in paragraph (F)(1) of this rule at least once every six months. (3) The agency will document in the staff personnel records that the training and demonstration of competency were successfully completed. Documentation will include the date training was completed and the name of persons certifying the completion of training. (4) All training programs and materials used by the agency will be available for review by the department. (G) Documentation. (1) The presence of advance directives or client preferences addressing the use of seclusion or restraint will be determined and considered, and documented in the ICR. If the provider will be unable to utilize seclusion or restraint in a manner in accordance with the person's directives or preferences, the provider will notify the individual, including the rationale, and document such in the ICR. (2) In conjunction with the person's active participation, an individual crisis plan will be developed at the time of admission and incorporated in the person's ITP for each child or adolescent resident of a department licensed residential facility or psychiatric residential treatment facility, for each client known to have experienced seclusion or restraint, for an individual who is at risk of harming themselves, and when otherwise clinically indicated. The plan will be based on the initial behavioral health assessment, and will include and be implemented, as feasible, in the following order: (a) Identification of the methods or tools to be used by the client to de-escalate and manage his or her own aggressive behavior; (b) Identification of techniques and strategies for staff in assisting the person to maintain control of his or her own behavior; and (c) Identification, in order of least restrictive to most restrictive, of the methods or tools to be used by staff to de-escalate and manage the client's aggressive behavior. (3) The provider will conduct an initial or comprehensive assessment for each child or adolescent resident of a department licensed residential facility, for each client known to have experienced seclusion or restraint, for an individual who is at risk of harming him/herself, and when otherwise clinically indicated for the following which may place the person at greater risk of physical or psychological injury as a result of the use of seclusion or restraint: (a) Gender; (b) Chronological and developmental age; (c) physical body size; (d) Culture, race, ethnicity, and primary language; (e) History of physical or 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 or alcohol use; (g) Physical disabilities; and (h) Psychiatric condition. (H) Logs and notifications. (1) A log will be maintained for department review of each incident of mechanical restraint, seclusion, and physical restraint, and for time-outs exceeding sixty minutes per episode. The log will include, at minimum, the following information: (a) The person's name; (b) The date, time and type of method or methods utilized, i.e., seclusion, mechanical restraint, physical restraint , or time-out. The log of mechanical restraint will also include the type of mechanical restraint device used; (c) The duration of the method or methods; and (d) The outcome of the intervention. (2) Pursuant to rules 5122-26-13 and 5122-30-16 of the Administrative Code, the provider will notify the department of each: (a) Instance of physical injury to a client or resident that is restraint-related, e.g., injuries incurred when being placed in seclusion or restraint or while in seclusion or restraint, with the exception of injury that is self-inflicted, i.e. a client or resident banging their own head; (b) Death that occurs while a person is restrained or in seclusion; (c) Death occurring within twenty four hours after the person has been removed from restraints or seclusion, and (d) 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. (I) Episode review and performance improvement. (1) Each incident of seclusion or restraint will be clinically and administratively reviewed. Such review will be documented. (2) The provider will collect the following data on all instances of the use of seclusion or restraint and integrate the data into performance improvement activities. (a) Staff involved, including staff member who initiated the seclusion or restraint; (b) Duration of the method; (c) Date, time and shift each method was initiated; (d) Day of week; (e) Type of method, including type of physical hold or mechanical restraints utilized; (f) Client age, race, gender and ethnicity; (g) Client and staff injuries; (h) Number of episodes per client; and (i) Use of psychotropic medications during an intervention of seclusion or restraint. (3) Data will be aggregated and reviewed at least semi-annually by providers and at least quarterly by department licensed residential facilities or certified addiction treatment residential/withdrawal management providers. The results of the review will be maintained in writing. Data will be reviewed: (a) For analysis of trends and patterns of use; and (b) To identify opportunities to reduce the use of seclusion or restraint episodes per client. (4) The results of data reviews and performance improvement activities will be shared with staff at least semi-annually with the goal of reducing the use of seclusion or restraint. (J) Plan to eliminate seclusion or restraint. (1) A provider which utilizes seclusion or restraint will develop a plan designed to reduce its use. The plan will include attention to the following strategies: (a) Identification of the role of leadership; (b) Use of data to inform practice; (c) Workforce development; (d) Identification and implementation of prevention strategies; (e) Identification of the role of clients (including children), families, and external advocates; and (f) Utilization of the post seclusion or restraint debriefing process. (2) A written status report will be prepared annually, and reviewed by leadership. (K) 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 this rule. (L) Each provider utilizing seclusion or restraint is responsible for identifying and adopting systems of seclusion and restraint techniques; and will assure that chosen systems meet all standards set forth in rules 5122-26-16 and 5122-26-16.1 of the Administrative Code and that staff that perform seclusion or restraint are trained in the proper use of those systems. Last updated October 20, 2023 at 12:59 AM Supplemental Information |
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Rule 5122-26-16.1 | Restraint and seclusion.
(A) The purpose of this rule is to state the specific requirements applicable to restraint and seclusion. (B) The requirements for the use of mechanical restraint or seclusion do not apply: (1) To mechanical restraint use that is only associated with medical, dental, diagnostic, or surgical procedures and is based on standard practice for the procedure. Such standard practice may or may not be described in procedure or practice descriptions (e.g., the requirements do not apply to medical immobilization in the form of surgical positioning, iv arm boards, radiotherapy procedures, electroconvulsive therapy, etc.); (2) When a device is used to meet the assessed needs of an individual who requires adaptive support (e.g., postural support, orthopedic appliances) or protective devices (e.g., helmets, tabletop chairs, bed rails, car seats). Such use is always based on the assessed needs of the individual. Periodic reassessment should assure that the restraint continues to meet an identified individual need; (3) To forensic and corrections restrictions used for security purposes, i.e., for custody, detention, and public safety reasons, and when not involved in the provision of health care. (C) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definitions apply to this rule: (1) "Licensed independent practitioner" means an individual who is authorized by the provider to order seclusion and restraint. A licensed independent practitioner includes a "medical practitioner authorized to order seclusion and restraint" as defined in this paragraph, as well as any other practitioner that has ordering seclusion and restraint in their scope of practice. (2) "Medical practitioner authorized to order seclusion and restraint" means an individual who is authorized by the provider to order seclusion and restraint and who is a psychiatrist or other physician, or a physician's assistant, certified nurse practitioner or clinical nurse specialist authorized to order restraint or seclusion in accordance with their scope of practice and as permitted by applicable law or regulation. (3) "Order" means written or verbal authorization to implement seclusion or restraint. (D) Restraint or seclusion will not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is possible. It will be employed for the least amount of time necessary in order that the individual may resume his/her treatment as quickly as possible. (E) The following are disallowed: (1) PRN and standing orders for seclusion or restraint. (2) Restraint and seclusion may not be used simultaneously. (3) Mechanical restraint may not be used on an individual under age eighteen. (F) Ordering restraint or seclusion. (1) For all settings other than a psychiatric residential treatment facility (PRTF), a physical restraint must be authorized by a trained, qualified staff member in accordance with the requirements of the providers' behavioral health national accrediting body or if the organization does not have national accreditation, as identified and approved by the provider's policy. A licensed independent practitioner or practitioner with dependent licensure under supervision will review each incident of physical restrain as soon as possible but not later than seventy-two hours, and if required by national accreditation body, provide an order for the physical restraint in the client records. (2) For all settings other than a PRTF, seclusion or mechanical restraint orders will be in writing and issued by a licensed independent practitioner or a practitioner with dependent licensure under supervision and include the date and time the order was written or obtained. (3) In a PRTF, the order for physical restraint, mechanical restraint, or seclusion, will be in writing and issued by a licensed independent practitioner or a practitioner with dependent licensure under supervision and include the date and time the order was written or obtained. (4) In all circumstances, the order for restraint or seclusion will be the least restrictive intervention that is most likely to be effective in resolving the emergency safety situation based on consultation with staff and specify the type of intervention and the maximum length of time. The order will also note the order is limited to the duration of the emergency safety situation. (5) Verbal orders. (a) When an individual authorized to order seclusion and restraint in paragraph (F)(2) or (F)(3) of this rule is not available in person to order restraint or seclusion or immediate intervention is required, agency policy may permit staff to obtain a verbal order from a licensed independent practitioner or a practitioner with dependent licensure under supervision while the restraint or seclusion is being initiated by staff or immediately after the intervention ends. (b) The verbal order will be signed by a licensed independent practitioner or a practitioner with dependent licensure under supervision or independent licensure, at least either by the end of the work day or in a residential setting during the next scheduled shift. (6) Written and verbal orders may be written for a maximum of: (a) Two hours for restraint or seclusion of adults eighteen years of age or older; (b) One hour for restraint or seclusion of children and adolescents age nine through seventeen; or (c) Thirty minutes for restraint or seclusion of children under age nine. (7) If restraint is necessary as a means of safely transporting an individual to seclusion, a separate order is not needed. However, the initial order for the seclusion will include the physical transport restraint and be consistent with the standards for restraint/seclusion orders. (8) If the restraint or seclusion continues past the original time in the order, staff will contact the individual who issued the original order who will issue a new written or verbal order if seclusion or restraint is to be continued. In a PRTF, a licensed practical nurse or registered nurse will be the person who contacts the medical practitioner, and a restraint or seclusion may not be continued past the time limits in paragraph (F)(6) of this rule. (9) If the restraint or seclusion episode is concluded, and the client's behavior necessitates initiating another restraint or seclusion, then a new order will be obtained, even if the ending time of the original order has not passed. (G) Implementation of restraint or seclusion. (1) Restraint or seclusion will be discontinued at the earliest possible time, regardless of the length of time identified in the order. (2) A trained and qualified practitioner with appropriate training in seclusion and restraint and in accordance with their scope of practice will conduct assessment of the physical and psychological well-being of the individual in accordance with the provider's national accrediting body. If not nationally accredited, a licensed practitioner will conduct the assessment within two hours of the initiation of the seclusion or restraint intervention. The assessment will either be conducted in person, face-to-face, or via interactive videoconferencing based on the individual's clinical and medical needs. Interactive videoconferencing will only be used if appropriate for the individual. In a PRTF, this assessment will be in person, face-to-face, within one hour of the initiation of the seclusion or restraint intervention and conducted by a medical practitioner authorized to order seclusion and restraint or a registered nurse. The assessment is to be conducted even if the seclusion or restraint intervention is ended before one hour. The assessment is to include, but is not limited to: (a) The individual 's physical and psychological status; (b) The individual 's behavior; (c) The appropriateness of the intervention measures; and (d) Any complications resulting from the intervention. (3) Monitoring while in and immediately after seclusion or restraint. (a) Restraint. (i) A staff trained in the use of restraint will be physically present, continually assessing and monitoring the physical and psychological well-being of the individual and the safe use throughout the duration of the intervention. (ii) Documentation of the condition of the person will be made in the clinical record at routine intervals not to exceed fifteen minutes or more often if the person's condition so warrants. Such documentation will address at a minimum, attention to respiration, the individual's physical status and behavior, the need for continued restraint, and other needs as necessary, and the appropriate actions taken. (b) Seclusion. (i) A staff trained in the use of seclusion will be physically present either in or immediately outside the seclusion room, continually assessing and monitoring the physical and psychological well-being of the individual and the safe use throughout the duration of the intervention. (ii) Documentation of the condition of the person will be made in the clinical record at routine intervals not to exceed fifteen minutes or more often if the person's condition so warrants. Such documentation will address at a minimum, attention to respiration, the individual's physical status and behavior, the need for continued seclusion, and other needs as necessary, and the appropriate actions taken. (iii) If seclusion lasts longer than ten minutes, the person will be given adequate access to the restroom and water at least every thirty minutes. (c) At the conclusion of the restraint or seclusion, a licensed medical staff will immediately check the resident for any injuries, evaluate the individual's psychological well-being and document the results. (4) Staff will assure that a client injured during a restraint or seclusion intervention receives immediate medical treatment that is appropriate for the specific injury, including transfer to a hospital for evaluation and treatment if needed. (5) Transitional holds are not seclusion or restraint, and are not subject to this rule. (H) Notification of the use of seclusion or restraint. (1) If the client is a minor, the provider will notify the parent(s), custodian(s) or legal guardian(s) of the individual who has been restrained or placed in seclusion as soon as possible after the initiation of each episode; and in a PRTF the notification will occur within twenty-four hours of the intervention.. (2) If the client is an adult, the provider will notify the client's guardian, when applicable, or family or significant other when the client has given their consent for such notification, within twenty-four hours of initiation of each episode. (3) The provider will document in the client's record that the notification was made, including the date and time of notification, the name of the person(s) notified and the name of the staff person providing the notification. (I) Debriefing. (1) Within twenty-four hours after the use of restraint or seclusion, all staff directly involved in a seclusion or restraint intervention and the client will have a face-to-face discussion. This discussion will include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the client. Other staff and the client parents, custodian or guardian may participate in the discussion when it is deemed appropriate by the provider. (a) The discussion will include the circumstances resulting in the use of seclusion or restraint. (b) The discussion will include identifying techniques and tools that might help the individual regulate their own behavior in the future and modifications to the individual's crisis plan. (c) The outcome and any injuries that may have resulted from the use of seclusion or restraint. (d) The discussion will include any other element as required by the provider's national accrediting body as part of a debriefing process. This may include a separate staff debriefing. (e) The debriefing will be conducted in a language understood by the client, and their parent, custodian, or guardian. (f) In non-PRTF settings the client debriefing may be delayed if the client refuses, is not available, or the debriefing is clinically not appropriate at that time. The debriefing will be conducted as soon as practical and prudent. (2) A PRTF, in addition to the briefing set forth in paragraph (I)(1) of this rule, will conduct a staff only debriefing session within twenty-four hours after the use of restraint or seclusion. The debriefing will include all staff involved in the intervention and appropriate supervisory and administrative staff. The debriefing session will include at a minimum a review and discussion of: (a) The situation that necessitated the intervention, including a discussion of the precipitating factors that led up to the intervention; (b) Alternative techniques that might have prevented the use of the restraint or seclusion; (c) The procedures, if any, that staff are to implement to prevent any recurrence of the use of restraint or seclusion; and (d) The outcome and any injuries that may have resulted from the use of restraint or seclusion. (3) Staff will document in the record for each client who is debriefed the number of debriefing sessions that took place, the names of staff who were present for the debriefing, names of staff that were excused from the debriefing, and any changes to the individual's treatment plan that result from the debriefings. (4) Debriefings may be conducted via virtual means. (J) Staff involved in a restraint or seclusion intervention that results in an injury to a client or staff will meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent future injuries. This documentation may be included with the client's debriefing or contained elsewhere. The plan to prevent future injuries is to include at a minimum attention to revised procedures, and new or additional staff training. (K) Documentation. Staff will document the intervention in the client's ICR. That documentation will be completed by either the end of the work day or the end of the shift in which the intervention occurs. In a residential setting if the intervention does not end during the shift in which it began, documentation will be completed during the shift in which it ends. Documentation will include all of the following: (1) Each order for restraint or seclusion as set forth in paragraph (F) of this rule. (2) The date, day of week, time and shift the restraint or seclusion began and the duration. (3) The type of method, including type of physical hold or mechanical restraint utilized. (4) The client's behavior that resulted in the client being restrained or put in seclusion. (5) Attempts to offer alternatives to the client based upon their crisis plan or de-escalation techniques, as applicable (6) Each attempt to use less restrictive interventions, and the results. (7) The time and results of the assessment in paragraph (G)(2) of this rule. (8) The time and results of the on-going monitoring in paragraph (G)(3) of this rule. (9) The name of all staff involved in the restraint or seclusion, including the staff that conducts the assessment and the staff who ordered the restraint or seclusion. (10) Any psychotropic medications utilized during the restraint or seclusion. (11) All injuries that occur as a result of the restraint or seclusion, including injuries to staff resulting from the intervention. Detailed information about any staff injury may be maintained outside the client's ICR. The appropriate actions taken for any injuries noted will also be documented. (L) Seclusion room requirements. The type of room in which seclusion is employed will ensure: (1) Appropriate temperature control, ventilation and lighting; (2) Safe wall and ceiling fixtures, with no sharp edges; (3) The presence of an observation window and, if necessary, wall mirror(s) so that all areas of the room are observable by staff from outside of the room; and (4) That any furniture present is removable or is securely fixed for safety reasons. (M) Clinically appropriate reason for the inability to implement any portion of this rule will be documented in the clinical record, and will be addressed in any staff de-briefing of the episode and in the provider's performance improvement process. Last updated October 20, 2023 at 12:59 AM Supplemental Information |
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Rule 5122-26-17 | Service accessibility and availability.
The provider shall have written policies, procedures, and processes that assure services are accessible and available to assure the following: (A) Continuity of care for persons discharged from psychiatric inpatient settings and referred to the provider through the provision of necessary services as determined by the provider in consultation with the person served and the referral source. Such necessary services shall be provided upon discharge whenever possible and no later than two weeks post discharge if it has been concluded during the discharge planning process that these services are required within two weeks; (B) With the exception of driver intervention programs that do not receive indigent funds from the department, providing assistance, as appropriate according to the person's needs, at no additional cost to persons served, to persons requesting or receiving services, and their families or significant others, who speak a language other than standard English as a primary means of communication, or who are individuals with a communication barrier, such as deafness or hearing impairment. Such assistance shall include availability of appropriate telecommunication relay services (TRS). A TRS is a telephone service that allows persons with hearing or speech disabilities to place and receive telephone calls, such services include but are not limited to text to speech relay and signing to speech relay. In situations when a client expresses a preference to communicate by use of a particular type of TRS, then the agency shall ensure one is available at the provider. Other assistance to be provided according to the needs of persons served shall apply to all forms of communication and shall include: (1) Interpreters fluent in the first vernacular language of the person served, and with demonstrated ability or certification; (2) Services provided by a professional who is able to communicate in the same vernacular language as the person served; and (3) Referral to a service that provides interpreters. (C) Addressing addiction and mental health service needs of the relevant community as described in the community plan of the board. (D) Referral to other systems or organizations if the provider does not provide such services to meet identified needs of persons with a severe mental disability or substance use disorder or children with severe emotional disturbance. Supplemental Information |
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Rule 5122-26-18 | Client rights and grievance procedure.
(A) The purpose of this rule is to state the minimum client rights and grievances requirements for a provider certified pursuant to Chapter 5122-25 of the Administrative Code. (B) The following definitions are in addition to or supersede the definitions in rule 5122-24-01 of the Administrative Code: (1) "Client advocate" means the individual designated by a provider with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within each provider or board, and shall have the same meaning as client rights officer or client rights specialist. (2) "Grievance" means a written complaint initiated either verbally or in writing by a client or by any other person or provider on behalf of a client regarding denial or abuse of any client's rights. (3) "Reasonable" means a standard for what is fair and appropriate under usual and ordinary circumstances. (C) Each provider shall have the following: (1) Written client rights policy that lists all of the client rights identified in this rule; (2) Written client grievance procedure; (3) Policy for maintaining for at least two years from resolution, records of client grievances that include, at a minimum, the following: (a) Copy of the grievance; (b) Documentation reflecting process used and resolution/remedy of the grievance; and, (c) Documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty business days. (D) Posting of client rights (1) The client rights policy and grievance procedure shall be posted in each location in which services are provided, unless the certified agency location is not under the control of the provider, i.e. a shared location such as a school, jail, etc. and it is not feasible for the provider to do so. (2) The client rights policy and grievance procedure shall be posted in a conspicuous location that is accessible to persons served, their family or significant others and the public. (3) When a location is not under the control of the provider and it is not feasible for the provider to post the client rights policy and grievance procedure, the provider shall assure that copies are available at the location for each person that may request a written copy. (E) Except for clients receiving forensic evaluation service as defined in rule 5122-29-07 of the Administrative Code from a certified forensic center, or attending a driver intervention program as defined in rule 5122-29-12 of the Administrative Code, each client has all of the following rights: (1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy; (2) The right to reasonable protection from physical, sexual or emotional abuse, neglect, and inhumane treatment; (3) The right to receive services in the least restrictive, feasible environment; (4) The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation; (5) The right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency; (6) The right to participate in the development, review and revision of one's own individualized treatment plan and receive a copy of it; (7) The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others; (8) The right to be informed and the right to refuse any unusual or hazardous treatment procedures; (9) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas; (10) The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations; (11) The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction; (12) The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary; (13) The right to be informed of the reason for denial of a service; (14) The right not to be discriminated against for receiving services 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 prohibited by local, state or federal laws; (15) The right to know the cost of services; (16) The right to be verbally informed of all client rights, and to receive a written copy upon request; (17) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations; (18) The right to file a grievance; (19) The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested; (20) The right to be informed of one's own condition; and, (21) The right to consult with an independent treatment specialist or legal counsel at one's own expense. (F) Client rights forensic evaluations. Each client receiving a forensic evaluation service from a certified forensic center has these rights: (1) The right to be treated with consideration and respect for personal dignity; (2) The right to be evaluated in a physical environment affording as much privacy as feasible; (3) The right to service in a humane setting which is the least restrictive feasible if such setting is under the control of the forensic center; (4) The right to be informed of the purpose and procedures of the evaluation service; (5) The right to consent to or refuse the forensic evaluation services and to be informed of the probable consequences of refusal; (6) The right to freedom from unnecessary restraint or seclusion if such restraint or seclusion is within the control of the forensic center; (7) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recordings, televisions, movies, or photographs, or other audio and visual technology, unless ordered by the court, in which case the client must be informed of such technique. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms; (8) The right not to be discriminated against in the provision of service 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 prohibited by local, state or federal laws; (9) The right to be fully informed of all rights; (10) The right to exercise any and all rights without reprisal in any form; (11) The right to file a grievance; and, (12) The right to have oral and written instructions for filing a grievance including an explanation that the filing of a grievance is exclusively an administrative proceeding within the mental health system and will not affect or delay the outcome of the criminal charges. (G) Client rights driver intervention programs: Each client participating in a driver intervention program has these rights: (1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy; (2) The right to reasonable protection from physical, sexual or emotional abuse and inhumane treatment; (3) The right to give informed consent to or to refuse any service: (4) The right to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others; (5) The right to be informed and the right to refuse any unusual or hazardous procedures; (6) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas; (7) The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations; (8) The right to have access to one's own client record; (9) The right to be informed of the reason for terminating participation in a service; (10) The right to be informed of the reason for denial of a service; (11) The right not to be discriminated against for receiving services 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 prohibited by local, state or federal laws; (12) The right to know the cost of services; (13) The right to be verbally informed of all client rights, and to receive a written copy upon request; (14) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations; (15) The right to file a grievance; (16) The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested; (17) The right to be informed of one's own condition; and, (18) The right to consult with an independent treatment specialist or legal counsel at one's own expense. (H) Provision of client rights (1) The provider shall explain and maintain documentation in the ICR of explanation of rights to each person served prior to or when beginning assessment or treatment services. (2) In a crisis or emergency situation, or when the client does not present for services in person such as through a hotline; the provider may verbally advise the client of at least the immediately pertinent rights only, such as the right to consent to or to refuse the offered treatment and the consequences of that agreement or refusal. Full verbal explanation of the client rights policy shall be provided at the first subsequent meeting. (3) Clients or recipients of referral and information service, consultation service, and prevention service as described in Chapter 5122-29 of the Administrative Code may have a copy and explanation of the client rights policy upon request. (4) Explanations of rights shall be in a manner appropriate for the person's understanding. (I) All staff shall be required to follow the client rights policy and client grievance procedure. There shall be documentation in each employee's personnel file, including contract staff, volunteers and student interns that each staff member has received a copy of the client rights policy and the client grievance procedure and has agreed to abide by them. (J) The client grievance procedure shall have provisions for at least the following: (1) Statement to whom the client is to give the grievance; (2) Designation of a client advocate who will be available to assist a client in filing of a grievance, the client advocate shall have their name, title, location, hours of availability, and telephone number included with the posting of client rights as required by paragraph (D) of this rule; (3) Requirement that the grievance must be put into writing; the grievance may be made verbally and the client advocate shall be responsible for preparing a written text of the grievance; (4) Requirement that the written grievance must be dated and signed by the client, the individual filing the grievance on behalf of the client, or have an attestation by the client advocate that the written grievance is a true and accurate representation of the client's grievance; (5) Requirement that the grievance include, if available, the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved; (6) Statement that the provider will make a resolution decision on the grievance within twenty business days of receipt of the grievance. Any extenuating circumstances indicating that this time period will need to be extended must be documented in the grievance file and written notification given to the client; (7) Statement that a client has the option to file a grievance with outside organizations, that include, but are not limited to, the following, with the mailing address and telephone numbers for each stated: (a) Applicable board of alcohol, drug addiction, and mental health services; (b) Ohio department of mental health and addiction services; (c) Disability rights Ohio; or, (d) U.S. department of health and human services, civil rights regional office in Chicago. (8) Requirement that a written acknowledgment of receipt of the grievance be provided to each grievant. Such acknowledgment shall be provided within three business days from receipt of the grievance. The written acknowledgment shall include, but not be limited to, the following: (a) Date grievance was received; (b) Summary of grievance; (c) Overview of grievance investigation process; (d) Timetable for completion of investigation and notification of resolution; and, (e) Treatment provider contact name, address and telephone number. Supplemental Information |