Rule 5160-59-09 | The OhioRISE program: incident management.
This rule sets the standards and procedures for managing incidents that may have a negative impact on youths. The purpose of this rule is to establish the procedures for reporting and addressing critical incidents and reportable incidents and to prevent and reduce the risk of harm to youths.
(A) For the purposes of this rule, the following definitions apply:
(1) "Care management entity" or "CME" means the agency described in rule 5160-59-03.2 of the Administrative Code.
(2) "Incident" means as defined in rule 5160-44-05 of the Administrative Code.
(3) "Incident management system" means as defined in rule 5160-44-05 of the Administrative Code.
(4) "Youth" means a person enrolled in the Ohio resilience through integrated systems and excellence (OhioRISE) program.
(5) "Individual crisis and safety plan" means as defined in rule 5160-59-01 of the Administrative Code.
(6) "Restraint" means any of the following:
(a) Chemical restraint, which is the use of any sedative psychotropic drug exclusively to manage or control behavior;
(b) Mechanical restraint, which is the use of any device to restrict a youth's movement or function for any purpose other than positioning or alignment;
(c) Physical restraint, which is the use of a hands-on or physical method to restrict the movement or function of a youth's head, neck, torso, one or more limbs, or the entire body.
(7) "Restrictive intervention" means any action or activity that limits a youth's right for a period of time to assure a youth's health, safety, or welfare. Restrictive intervention may only be used to safeguard youths from accident or injury or to help promote optimal health and welfare.
(8) "Seclusion" means any restriction that is used to address a specified behavior and that prevents the youth from leaving a location for a period of time.
(9) "Substantiated" means as defined in rule 5160-44-05 of the Administrative Code.
(10) "Unauthorized restraint" means as defined in rule 5160-44-05 of the Administrative Code.
(11) "Unauthorized restrictive intervention" means as defined in rule 5160-44-05 of the Administrative Code.
(12) "Unauthorized seclusion" means as defined in rule 5160-44-05 of the Administrative Code.
(B) The following incidents defined in paragraph (B) or rule 5160-44-05 of the Administrative Code will be reported and investigated as described in paragraph (D) of this rule:
(1) Critical incidents:
(a) Abuse.
(b) Behavioral support misuse.
(c) Neglect.
(d) Exploitation.
(e) Misappropriation.
(f) Unnatural or accidental death.
(g) Self-harm or suicide attempt.
(h) Medication error.
(i) The health and welfare of the youth is at risk due to the youth being lost or missing.
(2) Reportable incidents: natural death.
(C) This rule applies to youth enrolled in the OhioRISE program or the OhioRISE waiver who were not receiving treatment in a psychiatric residential treatment facility (PRTF) at the time the incident occurred, Incidents that occurred while a youth was receiving treatment in a PRTF are reported per rule 5160-59-03.6 of the Administrative Code.
(D) The following process will be followed upon the occurrence of an incident.
(1) Initial incident report.
(a) Upon discovering an incident, ODM, its delegates, CMEs, and providers of services under the OhioRISE program will:
(i) Take immediate action to ensure the health and welfare of the youth.
(ii) Report the incident to the OhioRISE plan immediately upon discovery of the incident, but no later than one business day after discovering the incident, unless bound by federal, state, or local law, or the requirements of professional licensure or certification to report sooner to the applicable statutory entity.
(b) All incident reports will include the following information when available:
(i) The facts relevant to the incident;
(ii) A description of what happened;
(iii) The incident type;
(iv) The date of the incident;
(v) The location of the incident;
(vi) The names and contract information of all persons involved; and
(vii) All actions taken to ensure the health and welfare of the youth.
(2) Receipt of report and documentation of the incident.
(a) Upon becoming aware of an incident, the OhioRISE plan, or its designee, will:
(i) Ensure immediate action was take to protect the health and welfare of the youth. If such action was not taken, take action immediately, but no later than twenty-four hours after the report was received.
(ii) Notify all of the appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies including but not limited to:
(a) Local law enforcement if the incident involves suspected criminal conduct;
(b) The local coroner's office when the death of a youth is reportable in accordance with section 313.12 of the Revised Code;
(c) The local county board of developmental disabilities;
(d) The local child protective services agency (CPS);
(e) The local adult protective services agency (APS);
(f) The Ohio department health, or other licensure or certification board or accreditation body if the incident involves a provider regulated by that entity;
(g) The local probate court if the incident may involve the legal guardian of the recipient.
(iii) Enter all critical incidents into the incident management system within one business day of becoming aware of the incident.
(iv) Enter all reportable incidents into the incident management system within three business days of becoming aware of the incident.
(3) Critical incident investigation.
(a) The OhioRISE plan, or its designee, will investigate all critical incidents by doing the following:
(i) Within two business days of entering the incident in the incident management system, initiate an investigation.
(ii) Conduct a review of all relevant documents including person-centered care plans, service plans, assessments, clinical notes, communication notes, results from an investigation conducted by a third-party entity when available, provider documentation, provider billing records, medical reports, police and fire department reports, and emergency response system reports.
(iii) Conduct and document interviews with everyone who may have information relevant to the incident.
(iv) Identify, to the extent possible, all causes and contributing factors.
(v) Determine whether the incident is substantiated.
(vi) Document all investigative activities in the incident management system.
(vii) Conclude the investigation no later than forty-five business days after the documented start date of the investigation, unless a longer timeframe has been previously approved by ODM.
(4) Follow-up and closeout responsibilities.
(a) For incidents that resulted in a CPS or APS referral, communicate a summary of the investigative findings to the relevant agency within seven business days after being notified that the investigation is complete.
(b) Except in the case of death, include any relevant information from the investigation when updating the individual crisis and safety plan to ensure the health and safety of the youth.
(c) For all substantiated critical incidents, except in the case of death, enter a prevention plan into the incident management system no later than seven business days after the conclusion of the investigation, indicating closure of the incident.
(d) For all reportable incidents, address and remediate the incident as determined appropriate, and close the incident in the incident management system no later than forty-five business days after submission of the incident in the incident management system.
(E) ODM may request further review of any incident, conduct a separate independent review or investigation of any incident, determine necessary additional action, or assume responsibility for conducting an investigation or review.
Last updated August 27, 2026 at 8:01 AM
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