Chapter 5122-27 | Minimum Requirements for Integrated Clinical Records

Rule 5122-27-01 | Applicability.

• Effective: October 31, 2019
• Promulgated Under: 119.03

(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) A board of alcohol, drug addiction, and mental health services.

(b) Federal or department block grant funding for certified services.

Any service contact provided by a provider that is paid for 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) Providing the following addiction treatment services, regardless of payor source:

(a) Residential and withdrawal management substance use disorder services provided in a setting other than an acute care hospital;

(b) Addiction services provided in a residential treatment setting;

(c) Addiction services provided on an outpatient basis, including one or more of the following addiction services provided on an outpatient basis:

(i) General services.

(ii) Crisis intervention service.

(iii) Peer recovery services.

(iv) SUD case management services.

This paragraph does not apply to either of the following:

An individual who holds a valid license, certificate, or registration issued by this state authorizing the practice of a health care profession that includes the performance of the services described in paragraphs (A)(2)(a) to (A)(2)(c) of this rule, regardless of whether the services are performed as part of a sole proprietorship, partnership, or group practice;

An individual who provides the services described in paragraphs (A)(2)(a) to (A)(2)(c) of this rule as part of an employment or contractual relationship with a hospital outpatient clinic that is accredited by an accreditation agency or organization approved by the director of mental health and addiction services.

(3) Subject to department certification as a driver intervention program according to section 5119.38 of the Revised Code.

(4) That voluntarily request certification.

(5) Is seeking licensure as an opioid treatment program in accordance with Chapter 5122-40 of the Administrative Code.

(B) These rules do not diminish or enhance the authority of 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.

(C) The provisions of the rules contained in this chapter are applicable to all services certified by the department; except for the following services and where specifically exempted:

(1) 5122-29-07 Forensic evaluation service;

(2) 5122-29-08 Behavioral health hotline service;

(3) 5122-29-12 Driver intervention program;

(4) 5122-29-15 Peer recovery services;

(5) 5122-29-16 Peer run organization;

(6) 5122-29-19 Consultation service;

(7) 5122-29-20 Prevention service;

(8) 5122-29-22 Referral and information service; and,

(9) 5122-29-27 Supplemental behavioral health services.

(D) Additional requirements for individual client records (ICR) may be specified in Chapter 5122-26 or Chapter 5122-29 of the Administrative Code.

(E) Modified requirements for record keeping apply to the following services:

(1) Behavioral health hotline service shall maintain a log of all telephone calls including but not limited to the following information:

(a) Reason for call;

(b) Presenting problem;

(c) Disposition and/or referral(s) made;

(d) Date, time and person receiving call; and

(e) Name of caller, if given.

(2) Forensic evaluation service shall maintain records according to rule 5122-29-07 of the Administrative Code, including the requirement to:

(a) Provide a written summary of the forensic evaluation to the court or adult parole authority; and

(b) Store reports of forensic evaluations and any related records separately from records of persons served in other services.

(3) Prevention services. Each provider shall maintain documentation for prevention services provided, which shall be documented per occurrence, and shall include, at a minimum, the following:

(a) Date the prevention service was provided.

(b) Location where the prevention service was provided.

(c) Approximate number of consumers who received the prevention service.

(d) Types of prevention strategies/services provided.

(e) Description of activities conducted.

(f) Signature of an individual who is qualified to provide prevention services in accordance with rule 5122-29-20 of the Administrative Code.

(4) Medical activities provided as part of general services pursuant to rule 5122-29-03 of the Administrative Code shall be shall be documented by progress notation, documentation of issuing a prescription, or review of test results.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 3/27/2022
Prior Effective Dates: 9/4/2003, 4/1/2016, 1/1/2018

Rule 5122-27-02 | Individual client record requirements.

• Effective: April 1, 2016
• Promulgated Under: 119.03

(A) Each provider shall maintain a complete and adequate individual client record for each client.

(B) An individual client record shall mean the account compiled by health and behavioral health care professionals of information pertaining to client health, addiction, and mental health; including, but not limited to, assessment of findings and diagnosis, treatment details, and progress notes.

(C) Documentation of consent for treatment, refusal to consent, or withdrawal of consent, shall be kept in the individual client record.

Consent by minors shall be in accordance with sections 5122.04 and 3719.012 of the Revised Code.

(D) A provider shall include documentation regarding:

(1) Service fees;

(2) The individual's, or individual's parent or guardian, responsibility for payment.

Responsibility for payment includes any portion not covered by insurance or other funding source.

(E) Documentation to reflect that the client was given a copy of the following:

(1) Service or program expectations of clients, if applicable. Examples include required attendance, or maintaining a sober environment, and consequences if client does not meet expectations.

(2) Summary of the federal laws and regulations that indicate the confidentiality of client records are protected as required by 42 C.F.R. part B, paragraph 2.22, if applicable.

(F) Each authorization for release of information form signed by the client.

(G) If provided, documentation verifying the client's attendance at alcoholism and drug addiction client-education.

(H) Providers shall maintain treatment records for at least seven years after a client has been discharged from a program or services are no longer provided, and prevention records for at least three years.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 3/27/2022

Rule 5122-27-03 | Treatment planning.

• Effective: November 7, 2019
• Promulgated Under: 119.03

(A) Each provider required by Chapter 5122-27 of the Administrative Code to maintain an individual client record (ICR) for a certified service, shall also develop an individualized treatment plan (ITP) for each client.

(B) The development of the ITP is a collaborative process between the client and service provider based on a diagnostic assessment, a continuing assessment of needs, and the identification of interventions and services appropriate to the individual's diagnosis and other related needs. An addiction treatment case management plan of care is based upon the diagnostic assessment or upon a separate case management assessment. Providers may accept a case management assessment from another provider as long as the assessment was completed with the preceding twelve months. Prior assessments shall be reviewed and updated prior to developing the case management plan.

(C) The ITP and addiction treatment case management plan of care shall document, at minimum, the following:

(1) A description of the specific mental health or addiction services and supports needs of the client;

(2) Anticipated treatment goals and objectives based upon the needs identified in this rule. Such goals shall be mutually agreed upon by the provider and the client. If these goals are not mutually agreed upon, the reason needs to be fully documented in the ICR;

(3) Name or description of all services being provided, with the exception of crisis intervention service provided in accordance with rule 5122-29-10 of the Administrative Code;

(4) Frequency of treatment services, and anticipated duration (e.g. sixty days, six months, a future date) of treatment services. A provider is not required to update a treatment plan solely because the anticipated period of treatment has passed;

(5) Documentation that the plan has been reviewed with the active participation of the client, and, as appropriate, with involvement of family members, parents, legal guardians or custodians or significant others;

(6) As relevant, the inability or refusal of the client to participate in service and treatment planning and the reason given;

(7) The dated signature of the agency staff member responsible for developing the ITP or addiction treatment case management plan of care, and documented evidence of clinical supervision of staff developing the plan, as applicable. Evidence of clinical supervision may be by supervisor signature on the ITP, addiction treatment case management plan of care, or other documentation by the supervisor in the ICR; and,

(8) For clients receiving addiction services treatment, the level of care to which client is admitted.

(D) A provider may develop separate ITP and addiction treatment case management plans or integrate the ITP and addiction treatment case management plan of care into one plan ("integrated plan").

(E) An initial ITP may be developed. An initial ITP is one which documents the immediate clinical needs of the client, and includes the items required of an ITP in paragraphs (C)(1),(C)(3), and (C)(7) of this rule to meet those immediate needs.

(F) Schedule of completion of ITP and addiction treatment case management plan of care:

(1) An initial ITP developed in accordance with paragraph (E) of this rule, if the provider chooses to develop an initial plan, shall be developed within seven days of completion of the assessment or at the time of the first face-to-face contact following assessment, whichever is later. A provider is not required to develop an initial ITP.

(2) An addiction treatment case management plan of care for a person receiving SUD case management services in accordance with rule 5122-29-09 of the Administrative Code shall be developed within seven days of completion of the assessment or at the time of the first face-to-face contact following assessment, whichever is later.

(3) A comprehensive ITP must be completed within five sessions or one month of admission, whichever is longer, excluding crisis intervention service provided in accordance with rule 5122-29-10 of the Administrative Code. This requirement is applicable regardless of whether the provider first developed an initial ITP in accordance with paragraph (E) of this rule.

(G) The addiction treatment case management plan of care shall be based upon a documented reassessment of case management needs. The reassessment must occur at least every ninety days.

(H) Schedule of review.

(1) An integrated ITP shall be reviewed at least every ninety days, and sooner if clinically indicated.

(2) An addiction treatment case management plan of care shall be reviewed at least every ninety days, and sooner if clinically indicated.

(3) An ITP that does not contain an addiction treatment case management plan of care shall be reviewed:

(a) When a service is added or terminated.

(b) When clinically indicated.

(c) When there is a change in the addiction treatment level of care, excluding a change in sub-levels, e.g. a change from level 3.5 to level 3.1 does not require a review of the treatment plan.

(d) When requested by the client.

(e) At least every twelve months.

(I) Documentation of ITP and addiction treatment case management plan of care reviews shall contain:

(1) Results of the review:

(a) Updates to the ITP and addiction treatment case management plan of care as applicable, e.g. new goals, discontinued or completed goals, adjusted anticipated duration, etc.; or

(b) Documentation that a review occurred without changes to the ITP and addiction treatment case management plan of care.

(2) Evidence that the plan has been reviewed with the active participation of the client, and, as appropriate, with involvement of family members, parents, legal guardians or custodians or significant others;

(3) As relevant, the inability or refusal of the client to participate and the reason given; and

(4) The signature of the provider staff member responsible for completing the review, the date on which it was completed; and documented evidence of clinical supervision of staff completing the review, as applicable.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 11/7/2024
Prior Effective Dates: 9/4/2003

Rule 5122-27-04 | Progress notes.

• Effective: October 31, 2019
• Promulgated Under: 119.03

(A) The provider shall document the progress or lack of progress toward the achievement of specified treatment goals identified on the ITP and the continuing need for services.

(B) Documentation of progress shall be done through brief narrative or checklists. Such documentation shall provide sufficient detail to address all required components.

(C) Progress notes shall be documented either on a per provision of the service basis, or on a daily or weekly basis.

(D) Service level progress notes shall include, at a minimum, the following:

(1) Client identification (name or identification number);

(2) The date, time of day, and duration of the service contact;

(3) The location of the service contact;

(4) A description of the service rendered;

(5) The assessment of the client's progress or lack of progress, and a brief description of progress made, if any;

(6) Significant changes or events in the life of the client, if applicable;

(7) Recommendation for modifications to the ITP, if applicable; and,

(8) The signature and credentials of the provider of the service and the date of the signature.

(E) Daily or weekly progress notes shall include, at a minimum, the following:

(1) Client identification (name or identification number);

(2) For daily progress notes, the calendar day the progress note is applicable to;

(3) For weekly progress notes, the weekly period, i.e. the continuous seven day period to which the progress note is applicable;

(4) The assessment of the client's progress or lack of progress, and a brief description of progress made, if any;

(5) Significant changes or events in the life of the client, if applicable;

(6) Recommendation for modifications to the ITP, if applicable; and,

(7) Date, original signature and credential of the staff member writing the daily or weekly progress note. The staff member must be qualified to provide all of the services documented in the daily or weekly service log.

(F) Client records utilizing daily or weekly progress notes must contain a service log that includes, at a minimum, the following:

(1) The date, time of day and duration of each service contact;

(2) The location of each service contact;

(3) A description of the service rendered; and,

(4) The signature and credential of each clinician who provided services during the day or week.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 3/27/2022
Prior Effective Dates: 2/15/2010, 4/1/2016

Rule 5122-27-05 | Discharge summary.

• Effective: October 31, 2019
• Promulgated Under: 119.03

(A) Each provider shall have policies and procedures addressing the completion of discharge summaries.

(B) The discharge summary shall include, but not be limited to, the following information:

(1) Date of admission of the client;

(2) Date of the last service provided to the client;

(3) Outcome of the service provided, i.e. amount of progress or the level of care;

(4) ASAM level of care at discharge, if applicable;

(5) Recommendations made to the client, as appropriate to the ITP, including referrals made to other community resources unless the client discontinued services without notice to the provider;

(6) Medications prescribed by the agency upon the client's termination from service;

(7) Upon involuntary termination from service, documentation that the client was informed of their right to file an appeal; and

(8) Dated signature and credentials of the staff member completing the summary.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 3/27/2022
Prior Effective Dates: 9/4/2003, 4/1/2016

Rule 5122-27-06 | Release of information.

• Effective: October 31, 2019
• Promulgated Under: 119.03

(A) Each request for information regarding a current or previous client shall be accompanied by an authorization for release of information, except as specified in sections 5119.27, 5119.28, and 5122.31 of the Revised Code.

(B) The authorization for release of information shall include, but not be limited to, the following:

(1) The full name of the client.

(2) Date of birth of the client.

(3) The specific information to be disclosed, and the purpose of the disclosure.

(4) The name of the person or entity disclosing the information.

(5) The name of the person or entity receiving the information.

(6) The date, event, or condition upon which the authorization shall expire.

(7) Statement that the consent is subject to revocation at any time except to the extent the provider or person who is to make the disclosure has already acted in reliance on it.

(8) Either a statement that the provider will not condition treatment, payment, enrollment, or eligibility on client's authorization for the release of information, or a statement of the consequences to the client if client refuses to sign an authorization for the release of information.

(9) The dated signature of the client or, as appropriate, a legally authorized agent and the agent's relationship to the client.

(10) For clients receiving addiction services treatment, the either of the following statements:

(a) "This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65."; or,

(b) "42 CFR part 2 prohibits unauthorized disclosure of these records."

(11) For records relating to mental health services, information from other providers that is contained in the individual client record may be released from the individual client record with the written authorization provided in accordance with the provisions of this rule. For records relating to addiction services, information from other providers that is contained in the individual client record may be released from the individual client record only if the written authorization provided in accordance with this rule explicitly authorizes both the disclosure of provider's records and the re-disclosure of the other provider's records.

(C) If the client is a minor, the release of information shall either:

(1) Be signed by the client's parent or legal guardian;

(2) In the case of providers who are certified to provide mental health services, may be signed by a client of fourteen years of age or older if all other requirements of section 5122.04 of the Revised Code are met;

(3) In the case of providers who are certified to provide addiction treatment services, be signed by the client and the client's parent or legal guardian; or,

(4) In the case of providers who are certified to provide addiction treatment services and minor client's providing consent to treatment pursuant to section 3719.012 of the Revised Code, the client shall sign the release of information.

(D) In the case of providers who are certified to provide addiction treatment services, when providing services to clients who are minors but who are not providing consent pursuant to section 3719.012 of the Revised code; the provider must either obtain the client's authorization to contact the client's parent or legal guardian or find the minor lacks in capacity to make a rational choice in accordance with 42 C.F.R. part 2.14(c)(2).

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 3/27/2022
Prior Effective Dates: 9/4/2003, 4/1/2016

Rule 5122-27-07 | Addiction treatment level of care.

• Effective: October 31, 2019
• Promulgated Under: 119.03

(A) The purpose of this rule is to establish criteria for assessing the appropriate level of care for each client receiving addiction services treatment.

(B) Providers shall determine level of care at admission, for continued stay, for change in level of care recommendation, and at discharge by conducting a multi-dimensional assessment utilizing the American society of addiction medicine criteria, also known as the ASAM patient placement criteria.

(C) When a client is placed in or referred to a level of care other than the assessed level of care, providers shall document the rationale.

Supplemental Information

Authorized By: 5119.36
Amplifies: 5119.36
Five Year Review Date: 10/31/2024