(A) The purpose of this rule is to promote and protect the rights of patients receiving services in Ohio's regional psychiatric hospitals (RPHs).
(B) The provisions of this rule apply to all RPHs providing inpatient services under the managing responsibility of the Ohio department of mental health and addiction services (OhioMHAS).
(C) As used in this rule:
(1) "Interested party" means a parent, spouse, other relative, significant other, or guardian of a patient or an advocacy group or interested citizen.
(2) "Patient" means a person who is currently or has received inpatient or outpatient services at or through an RPH.
(D) The policy of OhioMHAS is to promote and protect the rights of patients receiving services consistent with a concern for human dignity, respect, recovery, and quality clinical care; to respond promptly and effectively to patient and interested party concerns, inquiries, complaints, and grievances; and to promote and evaluate patient satisfaction with services provided.
(E) Organization and responsibilities of OhioMHAS's advocacy program:
(1) An OhioMHAS advocacy services administrator lead for inpatient services is to be appointed for the department.
General responsibilities of the OhioMHAS advocacy services administrator lead include, but are not limited to, the following:
(a) Providing support for the rights and recovery administrator within each RPH;
(b) Serving as the resource person for patient advocacy issues;
(c) Evaluating and reviewing OhioMHAS policies, procedures, and mechanisms for assurance of individual rights;
(d) Ensuring that alleged patient abuse and neglect cases receive prompt and appropriate action;
(e) Promoting liaison with federal, state, local, community, legal, and civil rights advocacy groups;
(f) Consulting with appropriate OhioMHAS staff, including the executive committee team, regarding complaints, grievances, and grievance appeals, including those having a potential impact on policy development;
(g) Referring matters requiring legal expertise in the area of patient rights to the department's office of legal services;
(h) Investigating and responding to patient grievance appeals;
(i) Meeting with RPH rights and recovery administrators on at least a quarterly basis;
(2) Each RPH is to have at least one full-time rights and recovery administrator for inpatient services, who reports directly to the RPH chief executive officer (CEO) or the CEO's designee.
Each RPH is to have a rights and recovery administrator alternate, appointed by the RPH CEO and who reports to the CEO or the CEO's designee.
(3) Duties for the each RPH rights and recovery administrator include, but are not limited to, the following:
(a) Planning, implementing, and coordinating RPH advocacy programs, including all of the following:
(i) Developing policies and procedures for the promotion and protection of human rights in accordance with state and federal statutes, joint commission guidance, and centers for medicare and medicaid services policy;
(ii) Monitoring and evaluating RPH compliance;
(iii) Establishing mechanisms for resolution of patient advocacy problems;
(iv) Providing consultation, negotiation, training, and technical advice; and
(v) Representing RPH on matters concerning patient rights.
(b) Providing patient advocacy services, including all of the following:
(i) Assuring adequate privacy for patient interviews;
(ii) Being accessible to patients in person and at work locations;
(iii) Representing and assisting patients especially in the areas of rights, abuse and neglect, and fulfillment of recovery and human dignity;
(iv) Investigating and responding to grievances on behalf of patients;
(v) Attending RPH investigatory interviews with patients, as requested by patients;
(vi) Protecting human and civil rights;
(vii) Reviewing unusual incident reports as part of the quality assurance process;
(viii) Ensuring that patients have legal representation at court hearings related to hospital services; and
(ix) Ensuring that patient rights are prominently displayed in writing on every unit.
(c) Attending meetings related to patient advocacy; serving as a member of the executive governing body and other committees to ensure representation of the hospital's advocacy program; preparing reports for RPH or campus administration and central office; maintaining records; and responding in writing to correspondence pertaining to patient advocacy;
(d) Providing input into program and environmental changes to meet the needs identified by patients and assuring protection of patient rights, as well as being involved in administrative decisions affecting patient rights, choice, dignity, and recovery;
(e) Advising all levels of RPH staff and volunteers of patient rights, as well as consulting with appropriate department staff, including legal staff, regarding policy issues and responses to complaints or grievances;
(f) Advocating for patient access to community mental health systems and facilitating access to outside entities, including legal counsel, as needed;
(g) Assuring that equal opportunity is implemented with particular emphasis on advocating that people with disabilities are free from discrimination in the provision of services on the basis of religion, race, ethnicity, color, creed, sex, national origin, age, lifestyle, sexual orientation, gender identity, physical or mental handicap, disability, developmental disability, or inability to pay as prescribed in department policies and rules and state and federal statutes;
(h) Ensuring that each patient understands the functions of and resources available through the Ohio protection and advocacy system and receives a copy of the patient rights in oral and written format in accordance with all of the following:
(i) The written rights are to be furnished to a patient within twenty-four hours after admission;
(ii) If a patient is unable to read or speaks a language other than standard English as a primary means of communication, or has a limitation on their ability to communicate effectively (such as deafness or hearing impairment), the list of rights is to be explained to them by providing interpreters, readers, or appropriate communication devices, or by providing other assistance; and
(iii) The notification and explanation of patient rights is to be documented in the patient's health record.
(4) Compliance with paragraph (D)(3)(h) of this rule will be monitored by the RPH quality assurance programs.
Last updated August 15, 2023 at 8:20 AM