OAC 5122-26

OAC 5122-26 Policies and Procedures for the Operation of Mental Health Services Agencies

This chapter establishes operational policies and procedures that all Ohio behavioral health providers of certifiable mental health and substance use disorder services must follow. Requirements cover governance and board structure, policy and procedure manuals, human resources management (including criminal background checks, orientation, supervision, and continuing education), confidentiality and clinical records security, service planning, continuity of care agreements, and environment of care. Providers operating opioid treatment programs and class one residential facilities are explicitly included in scope, along with any entity seeking certification for a broad range of behavioral health services.

This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and
 universities.

Chapter 5122-26 
|
 Policies and Procedures for the Operation of Mental Health Services Agencies

Ohio Administrative Code

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5122 

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Rule

Rule 5122-26-01 
|
 Purpose.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

The purpose of this chapter is to state the obligations for written policies and procedures for providers that provide certifiable services or supports.

Last updated August 3, 2026 at 8:25 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

1/1/1991, 4/1/2016

Rule 5122-26-02 
|
 Applicability.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) Statement of applicability
In general, the rules in this chapter apply to any person or government entity that provides or seeks to provide one or more certifiable services or supports, including (1) a person or government entity that operates or seeks to operate an opioid treatment program, (2) a person or government entity that operates or seeks to operate a class one residential facility as defined in section 
5119.34
 of the Revised Code, and (3) a board of alcohol, drug addiction, and mental health services that is, under section 
340.037
 of the Revised Code, approved by the director to provide any certifiable service or support. Paragraph (B) of this rule contains the exemptions from that general rule and paragraph (C) of this rule sets forth the specific standard that applies to federally-qualified health centers (FQHCs) and FQHC look-alikes.
A person or government entity to whom this chapter applies is referred to as a "provider."
(B) Exemptions
All of the following are exempt from the provisions of this chapter:
(1) In accordance with division (B) of section 
5119.35
 of the Revised Code, 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 any service that is required to be certified as described in this section, regardless of whether the service is performed as part of a sole proprietorship, partnership, or group practice.
(2) In accordance with division (B) of section 
5119.35
 of the Revised Code, an individual who provides any service that is required to be certified as described in this section 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 behavioral health. 
(3) A person or government entity where a rule specifically exempts that person or government entity from the rule obligation. 
(C) Specific standard applicable to federally-qualified health centers (FQHCs) and federally-qualified health center look-alikes (FQHC look-alikes)
(1) An FQHC or FQHC look-alike is subject to the rules in this chapter when the FQHC or FQHC look-alike provides or seeks to provide one or more of the following certifiable services or supports as part of the FQHC or FQHC look-alike designation as "out of scope":
(a) Mental health day treatment as described in rule 
5122-29-06
 of the Administrative Code.
(b) Forensic evaluation service as described in rule 
5122-29-07
 of the Administrative Code.
(c) Behavioral health hotline service as described in rule 
5122-29-08
 of the Administrative Code.
(d) Residential and withdrawal managements substance use disorder services as described in rule 
5122-29-09
 of the Administrative Code.
(e) Substance use disorder qualified residential treatment program (QRTP) for youth as described in rule 
5122-29-09.1
 of the Administrative Code.
(f) Crisis intervention service as described in rule 
5122-29-10
 of the Administrative Code.
(g) Employment service as described in rule 
5122-29-11
 of the Administrative Code.
(h) Driver intervention program as described in rule 
5122-29-12
 of the Administrative Code.
(i) SUD case management services as described in rule 
5122-29-13
 of the Administrative Code.
(j) Mobile response and stabilization service as described in rule 
5122-29-14
 of the Administrative Code.
(k) Peer support services as described in rule 
5122-29-15
 of the Administrative Code.
(l) Peer run organization as described in rule 
5122-29-16
 of the Administrative Code.
(m) Community psychiatric supportive treatment as described in rule 
5122-29-17
 of the Administrative Code.
(n) Therapeutic behavioral health services and psychosocial rehabilitation as described in rule 
5122-29-18
 of the Administrative Code.
(o) Prevention services as described in rule 
5122-29-20
 of the Administrative Code.
(p) Supplemental behavioral health services as described in rule 
5122-29-27
 of the Administrative Code.
(q) Intensive home-based treatment (IHBT) service as described in rule 
5122-29-28
 of the Administrative Code.
(r) Assertive community treatment as described in rule 
5122-29-29
 of the Administrative Code.
(2) An FQHC or FQHC look-alike is not subject to the rules in this chapter when the FQHC or FQHC look-alike provides or seeks to provide one or more of the following certifiable services or supports as part of the FQHC or FQHC look-alike designation as "in scope, other activities," including the provision of medication-assisted treatment as defined in section 
340.01
 of the Revised Code and the prescribing of one or more psychotropic drugs as defined in section 
5119.19
 of the Revised Code:
(a) General services as described in rule 
5122-29-03
 of the Administrative Code.
(b) Consultation service as described in rule 
5122-29-19
 of the Administrative Code.
(c) Referral and information service as described in rule 
5122-29-22
 of the Administrative Code.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

1/1/1991

Rule 5122-26-03 
|
 Governing body and governance.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) Each provider is to have a leadership structure. The leadership structure is to identify who is responsible for managing all of the following:
(1) Governance;
(2) Provider administration (i.e., planning, management, and operational activities); and
(3) The provision of certifiable services or supports.
(B) With respect to a provider that is a nonprofit corporation, governance of the provider is to be managed by a board of directors. The board is to develop written bylaws, policies, or a code of regulations covering all of the following:
(1) The selection of board members. The composition of the board is to reflect the demographics of the community the provider serves;
(2) The number of board members constituting a quorum;
(3) The terms of office for board members; and
(4) A ban on conflicts of interest between a board member and the provider.
(C) A board of directors of a provider that is a nonprofit corporation has all of the following duties:
(1) To organize and deliver an orientation program for new board members that includes information on governing structure, duties, responsibilities, and provider operations.
(2) To provide financial oversight and approve the provider's annual budget and plan for services.
(3) To conduct board meetings at least quarterly. Each board meeting is to include all of the following:
(a) A review of the most recent annual summary of quality assurance and risk management activities and documentation of the board actions taken as a result of the review;
(b) Approval of the performance improvement plan; and
(c) A review of the most recent annual summary of client rights activities and documentation of the board actions taken as a result of the review.
(4) To maintain board meeting minutes that include all of the following components:
(a) The date, time, and place of the meeting;
(b) The names of the board members who attended the meeting; and
(c) The topics discussed at the meeting and actions taken as a result of the meeting.
(5) To establish procedures for the selection of the provider's chief executive officer, executive director, or equivalent official.
(6) To establish the duties and responsibilities of the individual described in paragraph (C)(5) of this rule.
(7) To select the individual described in paragraph (C)(5) of this rule.
(8) To conduct an annual review and evaluation of the individual described in paragraph (C)(5) of this rule.
(9) To identify who is responsible for leading the provider in the absence of the individual described in paragraph (C)(5) of this rule.
(10) To establish, review, and update, as necessary, the provider's policies and document that this review has occurred. The policies are to be reviewed in accordance with the schedule established by the provider's national accrediting organization, if applicable, or at least every four years.
(11) To ensure the provider has procured adequate malpractice and liability insurance for all of the following and to review that insurance coverage not less than annually: the board; advisory board, if applicable; and provider and provider staff.
(12) To ensure that opportunities for input on planning, evaluation, delivery and operation of certifiable services or supports, including opportunities to participate on the board, advisory groups, committees, and other bodies, are offered to both of the following:
(a) Individuals who are receiving or have received certifiable services or supports and their family members; and
(b) Individuals who collectively represent a wide range of community interests and demographics of the service district in categories such as race, ethnicity, primary spoken language, gender, and socioeconomic status.
(13) To ensure that the hours of operation for certifiable services or supports accommodate the needs of individuals served and their family members and significant others.
(14) To ensure that all certifiable services or supports are delivered, and employment practices are implemented, in accordance with nondiscrimination provisions in federal law.
(D) With respect to a provider that is not a nonprofit corporation, including a provider that is a government entity, the provider is to describe its governance structure (i.e., whether the provider has a board of directors or other type of governing body).
(E) The governing body described under paragraph (D) of this rule has all of the following duties:
(1) To provide financial oversight and approve the provider's annual budget and plan for services.
(2) At least annually, do all of the following:
(a) Conduct a review of the most recent annual summary of quality assurance and risk management activities and document board actions taken as a result of the review;
(b) Approve the quality assurance plan; and
(c) Conduct a review of the most recent summary of client rights activities and document the board actions taken as a result of the review.
(3) To establish the duties and responsibilities of the provider's chief executive officer, executive director, or equivalent.
(4) To select the individual described in paragraph (E)(3) of this rule.
(5) To conduct an annual review and evaluation of the individual described in paragraph (E)(3) of this rule.
(6) To identify who is responsible for leading the provider in the absence of the individual described in paragraph (E)(3) of this rule.
(7) To establish, review, and update, as necessary, the provider's policies and document that this review has occurred. The policies are to be reviewed in accordance with the schedule established by the provider's national accrediting organization, if applicable, or at least every five years.
(8) To ensure the provider has procured adequate malpractice and liability insurance for all of the following and to review that insurance coverage not less than annually: the provider's corporate membership; advisory board, if applicable; and provider and provider staff.
(9) To ensure that opportunities for input on planning, evaluation, delivery, and operation of certifiable services or supports, including opportunities to participate on the governing body, advisory groups, committees, and other bodies, are offered to both of the following:
(a) Individuals who are receiving or have received certifiable services or supports and their family members; and
(b) Individuals who collectively represent a wide range of community interests and demographics of the service district in categories such as race, ethnicity, primary spoken language, gender, and socioeconomic status.
(10) To ensure that the hours of operation for services and activities accommodate the needs of individuals served and their family members and significant others.
(11) To ensure that all certifiable services or supports are delivered, and employment practices are implemented, in accordance with nondiscrimination provisions in federal law.
(F) Each provider is to maintain a written table of organization or organization chart that documents the lines of responsibility of all of the following:
(1) The board of directors or governing body, as applicable;
(2) The chief executive officer, executive officer, or equivalent official;
(3) Administrative leadership; and
(4) Clinical oversight.
(G) Each provider is to designate an individual to serve as its compliance officer and be responsible for overseeing, coordinating, implementing, and monitoring the provider's compliance with applicable federal and state laws, regulations, rules, certification and licensure standards, accreditation standards, and organizational policies and procedures. The designation of a compliance officer does not relieve the provider, its board of directors or governing authority, or other personnel of their responsibility to comply with applicable legal, regulatory, certification, licensure, and contractual standards. The compliance officer's responsibilities include, at a minimum, oversight, coordination, implementation, and monitoring of compliance with all of the following:
(1) Standards of the department of behavioral health, including certification, licensure, and credential verification standards; criminal records check standards; training standards; clinical and service-delivery standards; incident reporting, review and analysis of reportable incidents, and performance improvement standards; health and safety standards; and other applicable department standards;
(2) Standards of other state and local regulatory agencies having jurisdiction over the provider's operations;
(3) Professional licensure and credentialing standards applicable to personnel providing services on behalf of the provider;
(4) Other applicable state and federal laws, regulations, and funding mandates; and
(5) Regulatory changes affecting the provider's operations, services, programs, or funding.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

7/1/2011

Rule 5122-26-04 
|
 Policy and procedure manual.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) Each provider is to develop and comply with a written manual of policies and procedures regarding all activities of the provider and certifiable services and supports delivered by the provider.
(B) The policy and procedure manual will be available for review by staff, individuals served, and the family members and significant others of individuals served.
(C) The provider is to have a written policy and procedure describing how the provider ensures that staff assisting clients with telehealth services or providing telehealth services are adequately trained in equipment usage.
(D) A provider is to have a contingency plan for providing services or supports to clients when technical problems occur during a telehealth session.
(E) A provider is to maintain, at a minimum, the following local resource information:
(1) Contact information for the behavioral health hotline service as defined in rule 
5122-29-08
 of the Administrative Code; and
(2) Contact information for the local police and fire departments.
For purposes of this subparagraph, "local" means the area where the client indicates they reside and where they are receiving certifiable services or supports as indicated in paragraph (F) of rule 
5122-26-22
 of the Administrative Code. The provider is to provide the client with information regarding how to access assistance in a crisis, including one caused by equipment malfunction or failure. If a provider has a facility or unit that is serving as a client site, that site is to be maintained in such a manner that appropriate staff persons are on hand at the facility or unit in the event of a malfunction with equipment used to provide telehealth services.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

1/1/1991

Rule 5122-26-06 
|
 Human resources management.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) As used in this rule:
(1) "Individuals with disabilities" has the same meaning as in 34 U.S.C. 40104.
(2) "Personnel" or "staff member" means any paid or unpaid person, volunteer, contract worker, student intern, or other person who is part of a provider's workforce, including those who perform management, clinical, operations, clerical, or other functions in support of the provider's mission, vision, and goals.
(3) "Criminal records check" has the same meaning as in section 
109.572
 of the Revised Code.
(B) Human resources policies, procedures, and processes
A provider is to have human resources policies, procedures, and processes in place that ensure all of the following:
(1) The development of competent, qualified clinical and non-clinical staff;
(2) Appropriate and adequate supervision;
(3) Continuing education; and
(4) The maintenance of appropriate documentation.
(C) Job descriptions
A provider is to develop a job description for each position that includes all of the following:
(1) The minimum qualifications for the position, including academic standards, competencies (i.e., knowledge, skills, and experience), and licenses, certifications, registrations, or other credentials such as those mandated by an Ohio professional licensing board or federal agency (i.e., the United States drug enforcement agency for prescribers); and
(2) The duties and responsibilities of the position.
(D) Verification of licenses, certifications, registrations, or other credentials
Before employing or contracting with an individual, a provider is to verify that the individual possesses the necessary licenses, certifications, registrations, or other credentials for the position. The provider may accomplish this verification by making a copy of the individual's license, certification, registration, or other credential and noting the date and name of the individual who verified the credentials or printing or downloading a copy of the individual's license, certification, registration, or other credential record from a primary source, such as elicense Ohio professional licensure system, that shows the date the record was printed or downloaded and all of the following information regarding the individual:
(1) The individual's name;
(2) The individual's license number;
(3) The name of the board or agency issuing the licenses, certifications, registrations, or other credentials;
(4) The license type or name of the license;
(5) The date the license was issued; and
(6) The date that the license will expire.
(E) Criminal records checks
(1) Before employing or contracting with an individual or, in the case of a volunteer or student intern, allowing the individual to have contact with individuals served, a provider is to obtain consent from the individual to conduct a criminal records check of the individual. Once consent is received, the provider is to request that the superintendent of the bureau of criminal investigation, or a vendor approved by the bureau, conduct a criminal records check of the individual. Additionally, the provider is to request that the criminal records check conducted by the superintendent or the superintendent's approved vendor include information from the federal bureau of investigation in the criminal records check if the provider offers certifiable services or supports to individuals under eighteen years of age or individuals with disabilities under twenty-one years of age.
(2) A criminal records check of an individual, as described in this paragraph, is to be repeated every four years if the individual offers certifiable services or supports to individuals under eighteen years of age or individuals with disabilities under twenty-one years of age.
(3) A provider that is mandated to request information from the federal bureau of investigation as part of a criminal records check, as described in paragraph (E)(1) of this rule, may apply to the bureau of criminal investigation to become an approved recipient of national criminal history record information through the volunteer and employee criminal history system (VECHS) program. Information on the VECHS program, and an application for the program, is available at https://www.ohioattorneygeneral.gov/Files/Forms/Forms-for-BCI-Criminal-Records-and-Background-Chec/Quality-Assurance/VECHS-information-04-12-23.
(F) Services or supports to individuals under twenty-one years of age
A provider that offers certifiable services or supports to anyone under twenty-one years of age is to ensure both of the following, in addition to conducting a criminal records check in accordance with paragraph (E) of this rule:
(1) That each employee, contractor, volunteer, or student intern utilized in a position responsible for the direct care or supervision of anyone under twenty-one years of age is at least eighteen years of age; and
(2) That each employee, contractor, volunteer, or student intern, regardless of whether that individual is in a position responsible for direct care or supervision, has not pleaded guilty to nor been convicted of any offense specified in appendix B to rule 
5180:2-5-09.1
 of the Administrative Code except that such an individual who has been convicted of or pleaded guilty to such an offense may be an employee, contractor, volunteer, or student intern if both of the following are the case: 
(a) The offense involved is not a non-rehabilitation offense as specified in appendix B to rule 
5180:2-5-09.1
 of the Administrative Code; and 
(b) The provider has determined and documented that the rehabilitative criteria in appendix D to rule 
5180:2-5-09.1
 of the Administrative Code have been satisfied.
(G) Orientation training
A provider is to provide orientation training to staff and document the completion of such training not later than thirty calendar days after the first date of employment or having contact with individuals served. At a minimum, the orientation training is to include all of the following topics:
(1) Employee and client safety;
(2) The provider's mission, vision, and goals;
(3) The characteristics of the populations served;
(4) Sensitivity to cultural diversity;
(5) Policies and procedures specific to job duties and responsibilities;
(6) Confidentiality, including the responsibilities under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and, if applicable, 42 C.F.R. part 2;
(7) Reporting abuse and neglect policies and procedures; and
(8) Client rights and grievance policies and procedures.
(H) Scope of practice and supervision
(1) All personnel for whom a state or federal license, certification, registration, or other credential is mandated by law or regulation is to maintain the current license, certification, registration, or other credential issued by the appropriate Ohio or federal agency and is to practice only within the scope of that license, certification, registration, or other credential.
(2) Certifiable services or supports requiring supervision in accordance with Chapter 5122-29 of the Administrative Code are to be under the supervision of an individual who:
(a) Is eligible to supervise services or supports as set forth in rule 
5122-29-30
 of the Administrative Code; and
(b) Has a scope of practice in the area they are supervising as determined by the board that issues their professional license, certificate, or registration.
(3) Each non-supervisory staff member providing direct services or supports is to receive supervision in accordance with the mandates of the Ohio professional licensing board that issued the individual's license, certificate, or registration or, in the absence of such mandates, at regularly scheduled intervals appropriate to the staff member's skill level, experience, and job duties. Each occasion of supervision is to be formally documented by the supervisor of the non-supervisory staff member and maintained in the non-supervisory staff member's supervision record.
Supervision may be provided in individual and group sessions, including supervisor participation in treatment plan meetings.
(I) Continuing education
(1) A provider is to ensure direct service and supervisory staff participate in continuing education. To that end, each staff member is to complete the following, as applicable:
(a) If the staff member provides or supervises certifiable services or supports for which a license, certificate, or registration from an Ohio professional licensing board is necessary, at least the minimum number of continuing education hours prescribed by that board for each license, certificate, or registration renewal cycle.
(b) If the staff member provides or supervises services or supports that do not necessitate a license, certificate, or registration from an Ohio professional licensing board, at least twenty hours of continuing education every two years based on the individual's date of hire. If the staff member was originally hired in a position in which the staff member was not mandated to complete continuing education, but was later hired in such a position, the first twenty hours of continuing education are to be completed within two years of the first date of work in the new position. A staff member employed as of the effective date of this rule providing or supervising services or supports for which no license, certificate, or registration is issued by an Ohio professional licensing board is to complete the mandated continuing education within three years of the effective date of this rule, and every two years thereafter, based on the hire date or first date of work in the new position, as applicable.
(2) Continuing education is to maintain or increase competency, include topics specific to populations served, and include instruction to achieve cultural competence.
(J) Performance evaluation
A provider is to evaluate each staff member's performance at the frequency mandated by its national accrediting organization, if applicable, or, if for a provider without national accreditation, annually.
(K) Personnel files
A provider is to maintain a personnel file for each staff member. Personnel files are to be stored in such a manner as to maintain the privacy of each staff member. Provider policies are to describe who is to have access to the various information in the file. Each staff member is to have access to their own personnel file.
(1) With respect to each staff member, personnel files are to include all of the following:
(a) Identifying information.
(b) If the staff member possesses a license, certification, registration, or other credential from an Ohio professional licensing board or federal agency to perform certifiable services or supports or supervise certifiable services or supports, either an electronic verification or hard copy of that item. Alternatively, if the staff member does not need such an item to provide direct services or supports or supervise services or supports, documentation verifying that the staff member has achieved competency. Each provider is to establish the documentation necessary to verify competency in their personnel policies and procedures.
(c) A position title and description or, if the staff member is contract staff, a copy of the contract containing the staff member's title, duties, expectations, and necessary qualifications.
(d) Documentation that the staff member completed orientation training, including documentation that the staff member received a copy of the policies and procedures specified in paragraph (G) of this rule.
(e) Any disciplinary actions brought against the staff member.
(f) The results of each criminal records check conducted in accordance with paragraph (E) of this rule.
(g) Only if the staff member works for a provider that provides services subject to 42 C.F.R. part 2, documentation that the employee has reviewed and agreed to comply with those federal regulations. 
(h) Positions supervised by the staff member, if applicable.
(i) Compensation documentation, if applicable.
(2) In addition, with respect to each staff member, except for student interns and volunteers, personnel files are to include all of the following:
(a) The staff member's resume or application for employment, except that the provider's executive director, chief executive officer, president, or owner is exempted from this provision;
(b) Verification of references, if mandated for the position;
(c) The staff member's performance evaluations; and
(d) Documentation of continuing education and training in accordance with paragraph (I) of this rule for staff members that provide direct services or supports or supervise services or supports.
(L) A provider is to develop written human resources management policies and procedures that do all of the following:
(1) Forbid discrimination in employment, training, job duties, compensation, evaluation, promotion, and any other term or condition of employment based on race, ethnicity, age, color, religion, sex, national origin, sexual orientation, gender identity, physical or mental disability, developmental disability, genetic information, human immunodeficiency virus status, or any other factor disallowed by local, state, or federal law, and describe how the provider will monitor compliance with this standard and investigate complaints concerning violations of this standard.
(2) Describe a formal process for receiving employee grievances and investigating those grievances.
(3) Forbid sexual harassment.
(4) Establish code of conduct standards for all employees.
(5) Describe the grounds for termination of employment.
(6) Specify responsibilities concerning staff member access to, and disclosure of, an individual client's records, treatment information, diagnosis, and other protected health information. That policy is to be consistent with federal and state laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and, if applicable to the services and supports, 42 C.F.R. part 2.
(7) Establish a procedure for handling allegations of staff neglect or abuse of individuals served and the internal and external reporting that is to occur associated to responding to such allegations.
(8) Acknowledge the written client rights policy and written client grievance procedure specified in rule 
5122-26-18
 of the Administrative Code.
(9) Establish a disciplinary policy that specifies the actions that will be taken when there is employee misconduct or if the employee receives a criminal conviction that bears a direct and substantial relationship to that employee's position.
(10) Specify how employees will be notified of changes in the human resources policies and procedures described in this paragraph.
(M) A copy of the human resources policies and procedures described in paragraph (L) of this rule is to be given to each employee and each employee is to be notified when changes are made to those policies and procedures. The copy and any change notification may be given electronically. A provider is to make a notation in the staff member's personnel file when the staff member receives the copy or change notification.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

10/14/1982, 1/1/1991, 4/1/2016

Rule 5122-26-08 
|
 Confidentiality.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) A provider is to have a written policy on staff member access to, and disclosure of, an individual client's records, treatment information, diagnosis, and other protected health information. That policy is to be consistent with federal and state laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and, if applicable to the services and supports, 42 C.F.R. part 2.
(B) Storage of client records is to be in accordance with all applicable federal and state laws and regulations.
(C) All certified services or supports provided by telehealth are to begin with the verification of the client through a name and password or personal identification number and be provided in accordance with all state and federal laws, including those pertaining to the protection of patient information. Accordingly, a provider is to ensure that any username or password information and any electronic communications between the provider and client are securely transmitted and stored. All equipment used for telehealth is to be used in accordance with state and federal laws.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Rule 5122-26-08.1 
|
 Security of clinical records systems.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) A provider is to have policies and procedures addressing the security of its clinical records system.
(B) If a provider maintains electronic health records (EHRs), the system or module for maintaining the EHRs is to be certified in accordance with Title XXX of the Public Health Service Act (PHSA) and also comply with section 
3701.75
 of the Revised Code.
A provider is to be able to produce paper and/or electronic copies of client records when a request for such records has been made in accordance with law.
(C) Policies and procedures for providers maintaining an electronically-stored clinical records system are to include consideration of the following components:
(1) Multi-factor 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 necessitated 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 are to comply with section 
3701.75
 of the Revised Code.
(D) Security of records outside of an EHR - ensuring the security of data stored on personal desktop computers, laptops, portable hard drives, thumb drives, and similar devices by including a constraint that such records are accessible only through multi-factor authentication or are stored in a locked storage unit.
(E) Transfer of EHRs when operations cease - ensuring that if operations cease, EHRs are transferred in accordance with division (A)(15) of section 
5119.28
 of the Revised Code or, if applicable, 42 C.F.R. 
2.19
.

Last updated August 3, 2026 at 8:34 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Rule 5122-26-09 
|
 Provider service and support plan.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) The purpose of this rule is to ensure that each provider plans and develops certifiable services and supports to meet the needs of the populations they serve.
(B) A provider is to define in writing its mission, vision, and goals.
(C) A provider is to develop a written description of each certifiable service and support the provider provides, as well as any service or support the provider provides that is not certified by the department. The written description is to include all of the following:
(1) A detailed description of the service or support, including services or supports provided under each ASAM level of care, if applicable;
(2) A schedule of the days the service or support is available, as well as hours of operation;
(3) The needs and characteristics of the populations served; and
(4) The goals and the scope of the service or support.
(D) A provider is to specify in writing which services or supports are offered through referrals or affiliations with other providers and the responsibilities of each provider.
(E) A provider is to develop a policy concerning how often it will revise and update each service and support description. The policy is to mandate a revision to a service or support description when any of the information in paragraph (C) of this rule changes.
(F) A provider service and support plan is to be available for review by individuals served, their family, significant others, and the public. To that end, the provider service and support plan is to be available in paper or electronic format, as well as posted on the provider's website.

Last updated August 3, 2026 at 8:35 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Rule 5122-26-11 
|
 Continuity of care agreements.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

Each provider designated by a board of alcohol, drug addiction, and mental health services to screen, refer, or admit individuals to a state-operated psychiatric hospital is to have a signed continuity of care agreement describing the roles and responsibilities of the board, hospital, provider, and department.

Last updated August 3, 2026 at 8:35 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

2/17/2117

Prior Effective Dates:

1/1/1991

Rule 5122-26-12 
|
 Environment of care and safety.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) The purpose of this rule is to ensure that each provider maintains a clean, safe, and therapeutic environment to support the provision of certifiable services and supports and minimize the risk of harm to clients, visitors, and others.
(B) A provider is to designate the personnel who are responsible for implementing and overseeing the provisions of this rule. The personnel may be designated as an individual, position, or committee.
(C) A provider is to develop a written emergency preparedness plan that is consistent with guidance from the United States department of homeland security's website pertaining to business emergency plans, available at https://www.ready.gov/business/emergency-plans, and that same agency's website on active shooter situations: https://www.dhs.gov/xlibrary/assets/active_shooter_booklet.pdf. The plan is to address various types of emergency situations including fires, bomb threats, natural disasters, utility outages or malfunctions (e.g., gas leaks), active shooter situations, and other potential threats based on location (e.g., nuclear power plant leak). In addition, the plan is to address all of the following:
(1) Who is to provide initial and ongoing training on how to properly respond to the various types of emergency situations, the staff or positions to receive training, and the frequency of the on-going training. Regarding training, the plan is to specify all of the following:
(a) That initial training is to be completed and documented not later than thirty calendar days after the first date of employment or having contact with individuals served.
(b) That ongoing training is to be completed whenever there is a change in the emergency preparedness plan.
(c) That each training session that an employee attends is to be documented in the employee's personnel record.
(2) Where evacuation plans are to be posted and the frequency for updating them.
(3) The procedure for conducting emergency drills and how the effectiveness of such drills will be evaluated.
(a) With respect to fire drills, all of the following are the case:
(i) For provider locations offering services on a less than twenty-four hours a day basis, fire drills are to be conducted at least once every twelve months.
(ii) For residential and withdrawal management substance use disorder service providers, fire drills are to be conducted at least quarterly.
A driver intervention program is exempt from this subparagraph unless other services or programs are also available at the location.
(b) With respect to tornado drills, such drills are to be conducted at least annually.
(D) A provider is to develop written policies and procedures to address all of the following:
(1) Safe handling, storage, and disposal of hazardous materials;
(2) Safe handling and disposal of infectious waste materials, which are to include applicable specifications of the occupational safety and health administration within the United States department of labor and Ohio department of health;
(3) Infection control, which is to include applicable specifications of the occupational safety and health administration within the United States department of labor and Ohio department of health;
(4) The placement of carbon monoxide detectors and a ban on the use of unvented kerosene, gas, or oil heaters; and
(5) Hazardous areas on the premises of, or adjacent to, the provider's building or other structure (e.g., ponds, cliffs, etc.).
(E) A provider is to meet local, state, and federal laws regarding accessibility. If a provider identifies a structural or other barrier that limits access to a building or structure or access within the building or structure, the provider is to develop a plan for removing the barrier.
(F) A provider is to conduct regular walk-through and visual safety inspections at least every six months or more often as identified by the provider's policies and procedures or its national accrediting organization. The provider is to keep documentation regarding when these inspections occurred. Inspections are to include attention to all of the following:
(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 mandate in this paragraph.
(G) A provider is to obtain permits and associated inspections in accordance with local, state, and federal laws.
Driver intervention programs provided at motels, hotels, or camps are exempt from the mandate in this paragraph.
(1) A provider is to pass both of the following types of inspections at least once every twelve months:
(a) A fire inspection, including testing of fire alarms, conducted by a certified fire authority or, where one is not available, a fire inspection conducted by the division of the state fire marshal in the department of commerce.
(b) A water supply and sewage disposal inspection for facilities in which these systems are not connected with public services, for the purpose of certifying compliance with rules adopted by the Ohio department of health and any other state or local regulations, rules, codes, or ordinances.
(2) A provider is to pass all of the following inspections, as applicable, in accordance with the schedule prescribed by local or state law:
(a) An elevator inspection;
(b) A boiler inspection;
(c) A food service inspection;
(d) A swimming pool inspection; and
(e) Any other inspection mandated by local, state, or federal law.
(H) With respect to a client in need of a specialized diet, a provider is to maintain written documentation that the planning and preparation of meals is done in accordance with a plan and instructions issued by a physician or dietitian licensed by the state medical board of Ohio.
(I) A provider is to have equipment, including furnishings and records systems, that are in good and safe repair and suitable to the certifiable services and supports being provided by the provider.

Last updated August 3, 2026 at 8:35 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

10/31/2019

Rule 5122-26-13 
|
 Incident notification and risk management.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) The purpose of this rule is to establish standards to ensure that providers promptly and accurately notify the department of incidents specified in appendix A to this rule. This rule also mandates providers to review and analyze all incidents to identify issues and implement corrective measures designed to prevent reoccurrence and manage risk.
(B) Definitions
As used in this rule:
(1) "Board of residence" means the board of alcohol, drug addiction, and mental health services that is responsible for referring a client to treatment or paying for the client's treatment.
(2) "Incident" means an event that poses a danger to the health and safety of clients or staff of, or visitors to, the provider and is not consistent with the routine care of persons served or routine operation of the provider.
(3) "Reportable incident" means an incident, specified as a reportable incident in appendix A to this rule, that is to be reported to the department by a provider. As referenced in section 
5119.36
 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident."
(4) "Six month reportable incident" means an incident, specified as a six month reportable incident in appendix A to this rule, that is to be reported electronically through the department's incident reporting system. A six month reportable incident is not the same as a reportable incident.
(5) "Six month incident data report" means a data report that has to be submitted to the department.
(C) Incident reporting system
A provider, regardless of accreditation status, is to develop a policy concerning its reporting of reportable incidents to the department. In addition, the provider is to develop an incident reporting system that includes a mechanism for the provider's review and analysis of reportable incidents and other incidents to ensure that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to clients, staff, and visitors. In the policy and procedure, the provider is to identify what constitutes an "other incident" as referenced in this paragraph. Under the reporting system, all of the following are the case:
(1) The provider will maintain a log of its reportable incidents and other incidents for department review.
(2) The provider will periodically review and analyze reportable incidents and other incidents. This process is to include a review of incident reports the provider receives from class two and class three residential facilities defined in division (B) of section 
5119.34
 of the Revised Code regarding individuals served by the provider, as well as any actions taken by the provider.
(3) Provider staff will submit a written incident report to the provider's executive director or designee not later than twenty-four hours after discovery of the reportable incident.
(D) Abuse or neglect reports
(1) A person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect, of a child or adolescent is to immediately notify the appropriate public children's services agency or peace officer of that knowledge in accordance with section 
2151.421
 of the Revised Code.
(2) A person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect, of an adult aged sixty or over is to immediately notify the appropriate county department of job and family services of that knowledge in accordance with section 
5101.63
 of the Revised Code.
(E) Submission of reports to the department
(1) Reportable incident reports
(a) A provider is to submit a report to the department regarding each occurrence of a reportable incident. If more than one category of incident is applicable per occurrence, then all are to be reported in the same report. The report is to include all of the following information:
(i) The provider's name;
(ii) The date of the incident;
(iii) The date of discovery of the incident;
(iv) The date the incident was reported to the department;
(v) The type of incident and the incident report category;
(vi) Information regarding all clients that has been deidentified in accordance with HIPAA regulations (45 C.F.R. 164.514(b)(2)) and, if applicable, regulations in 42 C.F.R. Part 2; and
(vii) Information regarding all staff and, if applicable, visitors involved with the incident.
(b) A provider is to submit a report under this subparagraph to the department and the appropriate board of residence not later than twenty-four hours after discovery of the incident, excluding weekends and holidays. If after submitting a report a provider learns that the incident involves an additional incident report category, the provider, within the aforementioned time frame, is to either amend the report or submit a new incident report including only the new incident category and information.
(2) Six month incident data reports
A provider is to submit a six month incident data report to the department and appropriate board of alcohol, drug addiction, and mental health services through the department's incident reporting system as follows:
(a) For the period beginning January first and ending June thirtieth of each year, the report is to be submitted not later than July thirty-first of the same year.
(b) For the period beginning July first and ending December thirty-first of each year, the report is to be submitted not later than January thirty-first of the immediately following year.
(F) The department may initiate follow-up and further investigation of a reportable incident or six month reportable incident, as the department determines necessary, and may request a follow- up and further investigation by the provider, regulatory or enforcement authority, or the board.

View Appendix

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

1/1/2012, 6/1/2017

Rule 5122-26-14 
|
 Provider closing or acquisition.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

A provider certified by the department that intends to voluntarily close has certain responsibilities to fulfill with respect to its clients, the department, and boards of alcohol, drug addiction, and mental health services.
(A) Responsibilities to clients
A provider has all of the following responsibilities to fulfill with respect to each client:
(1) Not less than sixty days before the intended date of closure, the provider is to give each client written notice of the closure and document in the client's record that the notice was given. If the client is a minor, the provider is to send notice to the minor client's parent and the minor in accordance with section 
3719.012
 of the Revised Code.
(2) If the client will need ongoing certifiable services or supports after the projected closing date, the provider is to do both of the following:
(a) Refer the client to another provider certified or licensed by the department or to an individual who is licensed or certified to provide the needed certifiable services or supports; and
(b) Have documentation that shows that the provider or a licensed or certified individual, as described in paragraph (A)(2)(a) of this rule, has accepted the client for admission. This standard is satisfied if there is a case note in the client's record stating the date, time, and place that the client is scheduled for an intake interview with the other provider or licensed or certified individual.
(B) Responsibilities to the department
A provider has all of the following responsibilities to fulfill with respect to the department:
(1) Not less than sixty days before the intended date of closure, the provider is to give written notice of the closure to the department's office of legal services.
(2) The provider is to provide to the department any copies of, or access to, books, documents, papers, or other records requested by the department, including records concerning clients.
(3) The provider is to return any unused government funds to the distributor of the funds and provide to the department a report that specifies all of the following:
(a) A list of each person or government entity to which the provider returned unused funds, the amount returned, and the date the return occurred;
(b) A list of all unused materials that were paid for by government funds and a description of the final disposition of such materials; and
(c) A list of all equipment that was paid for by government funds and a description of the final disposition of such equipment.
(C) Responsibilities to boards of alcohol, drug addiction, and mental health services
A provider has the following responsibilities to fulfill with respect to each board of alcohol, drug addiction, and mental health services of the alcohol, drug addiction, and mental health services districts in which the provider offers certifiable services and supports:
(1) The provider is to send to the board a copy of each notice sent to a client under paragraph (A)(1) of this rule; and
(2) In accordance with division (A)(15) of section 
5119.28
 of the Revised Code, a provider is to transfer to the board any client records it possesses that have not been transferred to another provider. Before effectuating the transfer, the provider is to notify the board of its intent to send the records and receive instructions from the board on the format in which the records are to be sent. In addition, the provider incurs all expenses of effectuating the transfer and storing the records.
(D) Debarment
If a provider fails to comply with this rule, the department may, for a period not exceeding three years, debar the provider from being considered for any contract awards managed or otherwise handled by the department. If the department debars a provider under this rule, the department will notify the directors of administrative services and medicaid of the debarment.

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

4/1/2016

Rule 5122-26-15 
|
 Medication handling and theft.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(A) A provider is to 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 are to include all of the following mandates:
(1) The provider is to possess a valid and current terminal distributor of dangerous drugs license from the state board of pharmacy if the provider maintains a stock supply of prescription medications, participates with the department's central pharmacy to receive dispensed prescriptions, or when otherwise necessitated by rules of the state board of pharmacy.
(2) The provider is to store all prescription blanks in a locked, secure area.
(3) The provider is to designate a person who will have access to or may handle medications and is to maintain a current list of these persons, their credentials, and their medication handling responsibilities.
(4) The provider is to provide a method to record and follow the medications from the time of receipt to the time of distribution, return to central pharmacy, donation to a drug repository program operated pursuant to Chapter 4729:5-10 of the Administrative Code, or destruction. This record is to be retained by the provider for three years and will include the following information:
(a) The date and time the medication was received by the provider, distributed to individuals served, returned to central pharmacy, donated to a drug repository program or, if appropriate, destroyed;
(b) The name, credentials, and signature of all persons handling medications;
(c) A provision stating that unused medications prescribed for an individual are to be appropriately destroyed or returned to central pharmacy, unless the unused medications have been donated to a drug repository program; and
(d) A provision stating that unused medications will not be issued to another individual unless that issuance is done through a drug repository program. Return of unused medications prescribed to an individual is only allowed when the return is to central pharmacy in accordance with rule 
4729:5-3-16
 of the Administrative Code.
(5) The provider is to ensure that all staff handling medications have basic and ongoing instruction and training in safe and effective handling of medications.
(6) The provider is to ensure that medications are handled only by authorized persons and that others do not have access to the medications.
(7) The provider is to ensure that controlled substances are destroyed in accordance with rule 
4729:5-3-01
 of the Administrative Code.
(B) Providers maintaining a limited stock supply of medications are to do both of the following:
(1) Allow only a physician or pharmacist to dispense medications, although a clinical nurse specialist, certified nurse practitioner, or physician assistant may personally furnish controlled substances in accordance with section 
3719.06
 of the Revised Code or personally furnish dangerous drugs that are not controlled substances in accordance with section 
4723.481
 or 
4730.43
 of the Revised Code, as appliable; and
(2) Have posted in a conspicuous location the phone number of the Ohio poison centers.
(C) A provider is to describe in its policies and procedures whether a client is permitted to possess prescription and over-the-counter medication while at the provider site and whether they may self-administer medication at the provider site.
A provider that permits a client to possess prescription and over-the-counter medication at the provider site is to have written procedures that address this authority.
A provider that does not permit clients to possess prescription and over-the-counter medication at the provider site is to have written procedures for taking possession of, accounting for, and returning such medication to the client at the time of the client's departure or discharge.
A provider that permits a client to self-administer medication is to have written policies and procedures that address this authority.
(D) The provider is to have a policy on employee medication theft and is to inform all employees concerning this policy. The policy is to 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 is to 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 is to notify the department.
The provider is to take all reasonable steps to protect the confidentiality of the information and the identity of the person furnishing the information.
(2) Suspected medication theft is also to be reported to the state board of pharmacy. For controlled substances, suspected medication theft is also to be reported to the federal drug enforcement administration. Providers participating in medication services with the department's central pharmacy are to also notify central pharmacy.
(3) Failure to report information of medication theft is to 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 is to 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.

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

10/31/2019

Rule 5122-26-16 
|
 Seclusion, restraint and time-out.

Effective:

October 20, 2023

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(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

Authorized By:

5119.36

Amplifies:

5119.36

Five Year Review Date:

10/20/2028

Prior Effective Dates:

1/1/1991

Rule 5122-26-16.1 
|
 Restraint and seclusion.

Effective:

October 20, 2023

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

(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

Authorized By:

5119.36

Amplifies:

5119.36

Five Year Review Date:

10/20/2028

Prior Effective Dates:

1/1/1991, 1/1/2012

Rule 5122-26-17 
|
 Service and support accessibility and availability.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

Download Authenticated PDF

A provider is to have written policies, procedures, and processes to ensure certifiable services and supports are accessible and available. Those policies, procedures, and processes are to address all of the following:
(A) The continuity of care for an individual who is already a client of the provider, who is discharged from a psychiatric inpatient setting, and who is referred to necessary services or supports as determined by the provider in consultation with the individual served, that individual's guardian (if applicable), and the referral source. Necessary services or supports are to be provided to such an individual not later than two weeks after discharge unless clinical staff at the psychiatric inpatient setting determine that the services or supports are not needed within that time frame.
(B) The provision of communication assistance to an individual requesting or receiving certifiable services or supports from the provider or to a family member or significant other of that individual, because of limited English proficiency, deafness or other hearing impairment, or another communication barrier.
(1) With respect to assistance for an individual with limited English proficiency or communication barrier, the assistance is to include at least one of the following:
(a) An interpreter fluent in the language of the individual with demonstrated ability or certification;
(b) Interpretation provided by a professional who is able to communicate in the same language as the individual; or
(c) Referral to a service that provides interpreters.
(2) With respect to assistance for an individual with deafness or other hearing impairment, the assistance is to include the availability of appropriate telecommunications relay services (TRS). In situations when an individual expresses a preference to communicate by use of a particular type of TRS, the provider is to ensure one is available.
(C) The certifiable service or support needs of the relevant community as described in the community plan of the board or boards.
(D) Referral to other systems or organizations if the provider does not provide the services or supports necessary to meet the needs of clients.
(E) The steps the provider takes to comply with Title II of the Americans with Disabilities Act of 1990, 42 U.S.C. 12131 et seq., or Title III of the Americans with Disabilities Act of 1990, 42 U.S.C. 12182 et seq., as applicable. 

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

10/31/2019

Rule 5122-26-18 
|
 Client rights and grievance procedure.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

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(A) As used in this rule:
(1) "Client advocate" means the individual designated by a provider with responsibility for ensuring compliance with the client rights and grievance procedure rule as implemented within each provider or board. "Client advocate" has 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 individual or provider on behalf of a client regarding denial or abuse of any client's rights.
(B) Each provider is to have all of the following:
(1) A written client rights policy that lists all of the client rights identified in this rule;
(2) A written client grievance procedure;
(3) A policy for maintaining, for at least two years from resolution, records of client grievances that include, at a minimum, the following:
(a) 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.
(C) Posting of client rights
(1) The client rights policy and grievance procedure is to be posted as follows:
(a) In each location in which services are provided, unless the provider 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); and
(b) On the provider's website in a conspicuous location, along with contact information for the client advocate. At a minimum, the contact information for the client advocate includes the client advocate's name, telephone number, and email address.
(2) The client rights policy and grievance procedure is to be posted in a conspicuous location that is accessible to individuals 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 is to assure that copies are available at the location for each individual that may request a written copy.
(D) 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 protection from physical, sexual or emotional abuse, neglect, and inhumane treatment and sexual exploitation.
(3) The right to receive services or supports in the least restrictive, feasible environment.
(4) The right to participate in any appropriate and available service or support that is consistent with an individualized treatment plan, regardless of the refusal of any other certified service or support, unless that certified service or support is a necessity for clear treatment reasons and involves the individual's participation.
(5) The right to give informed consent to or to refuse any certifiable service or support.
(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 of and 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 exclude a provider 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 constraints for disclosure of client information under state and federal laws and regulations.
With respect to an adult client receiving residential and withdrawal management substance use disorder services as described in rule 
5122-29-09
 of the Administrative Code, the right to confidentiality of communications includes the right to write or receive uncensored, unopened correspondence subject to the provider's rules regarding contraband when such rules do not conflict with federal postal regulations.
With respect to an unemancipated minor client receiving residential and withdrawal management substance use disorder services as described in rule 
5122-29-09
 of the Administrative Code, the right to confidentiality of communications includes the right to write or receive mail subject to the provider's policy regarding contraband and directives from the parent or legal guardian, when such rules and directives do not conflict with federal postal 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 is to 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 in advance of the reason for terminating participation in a certifiable service or support, and to be provided a referral, unless the certifiable service or support is unavailable or not necessary.
(13) The right to be informed of the reason for denial of a certifiable service or support.
(14) The right not to be discriminated against for receiving certifiable services or supports 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 forbidden by local, state or federal laws.
(15) The right to know the cost of certifiable services or supports.
(16) The right to be verbally informed of all client rights and 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.
(21) The right to consult with an independent treatment specialist or legal counsel at one's own expense.
(E) Client rights - forensic evaluations
A client receiving a forensic evaluation service from a certified forensic center has all of 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 has to be informed of such technique. This right does not exclude a provider 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 certifiable services or supports 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 forbidden 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.
(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 behavioral health system regulated by the department and will not affect or delay the outcome of the criminal charges.
(F) Client rights - driver intervention programs
Each client participating in a driver intervention program has all of these rights:
(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.
(2) The right to protection from physical, sexual or emotional abuse and inhumane treatment.
(3) The right to give informed consent to or to refuse any certifiable service or support.
(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 of and 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 exclude a provider 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 constraints 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 certifiable service or support.
(10) The right to be informed of the reason for denial of a certifiable service or support.
(11) The right not to be discriminated against for receiving certifiable services or supports 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 forbidden by local, state or federal laws.
(12) The right to know the cost of certifiable services or supports.
(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.
(18) The right to consult with an independent treatment specialist or legal counsel at one's own expense.
(G) Provision of client rights
(1) The provider is to explain and maintain documentation in the ICR of explanation of rights to each individual served prior to or when beginning assessment or certifiable treatment services or supports.
(2) In a crisis or emergency situation, or when the client does not present for certifiable services or supports 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 is to be provided at the first subsequent meeting.
(3) Clients or recipients of referral and information service or consultation 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 is to be in a manner appropriate for the individual's understanding.
(H) All staff are expected to follow the client rights policy and client grievance procedure. There is to be documentation in each employee's personnel file, including the file of 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.
(I) The client grievance procedure is to have provisions for at least the following:
(1) Statement to whom the client is to give the grievance. At least one person to whom the client may give a grievance will be available on site during a core number of hours each day the provider is open. This person does not have to be a client advocate but is to be a person trained to receive a grievance and pass it along to the client advocate.
(2) Designation of one or more client advocates who will be available onsite or through videoconferencing or other virtual means for a core number of hours each week the provider is open to assist the client in filing a grievance. If the provider offers a videoconferencing or other virtual option for access to a client advocate, the provider is to offer each client who chooses to access the client advocate in this way a private space on the provider's premises, along with the necessary equipment, to meet with the client advocate through videoconferencing or other virtual means. The client advocate is to have their name, title, location, hours of availability, telephone number, and email address included with the posting of client rights as necessitated by paragraph (C) of this rule.
(3) Necessitate that the grievance be in writing. The grievance may be made verbally and the client advocate is to be responsible for preparing a written text of the grievance.
(4) Necessitate that the written grievance is to 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) Necessitate 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 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 has to 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 behavioral health;
(c) Disability rights Ohio; and
(d) U.S. department of health and human services, civil rights regional office in Chicago.
(8) Necessitate that a written acknowledgment of receipt of the grievance be provided to each grievant. Such acknowledgment is to be provided within three business days from receipt of the grievance. The written acknowledgment is to 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) Provider contact name, address, and telephone number.

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

5/10/1979, 1/1/1991, 3/1/2012

Rule 5122-26-22 
|
 Telehealth.

Effective:

August 1, 2026

Promulgated Under:

119.03

PDF:

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(A) As used in this chapter and Chapter 5122-29 of the Administrative Code, "telehealth services" or "telehealth" have the same meaning as "telehealth services" in section 
5119.368
 of the Revised Code.
(B) No in-person visit is necessary to initiate telehealth services. The decision of whether to provide certifiable services or supports by telehealth is to be based on client choice, appropriate clinical decision-making, and professional responsibility, including the mandates of professional licensing, registration, or credentialing boards.
Regarding client choice and providers that have clients who are residents of a recovery housing residence or class two or class three residential facility, such providers are not to mandate or pressure those clients to receive a certifiable service or support by telehealth, whether individually or in a group format.
(C) The following are the certifiable services and supports that may be provided through telehealth:
(1) General services as defined in rule 
5122-29-03
 of the Administrative Code, except for the collection of urine specimens for urinalysis; 
(2) Community psychiatric supportive treatment (CPST) service as defined in rule 
5122-29-17
 of the Administrative Code;
(3) Therapeutic behavioral service and psychosocial rehabilitation as defined in rule 5122-29- 18 of the Administrative Code;
(4) Peer support services as defined in rule 
5122-29-15
 of the Administrative Code;
(5) SUD case management service as defined in rule 
5122-29-13
 of the Administrative Code;
(6) Crisis intervention service as defined in rule 
5122-29-10
 of the Administrative Code;
(7) Assertive community treatment as defined in rule 
5122-29-29
 of the Administrative Code;
(8) Intensive home-based treatment service as defined in rule 
5122-29-28
 of the Administrative Code; and
(9) Mobile response and stabilization service as defined in rule 
5122-29-14
 of the Administrative Code.
(D) An individual receiving residential and withdrawal management substance use disorder services as defined in rule 
5122-29-09
 of the Administrative Code or mental health day treatment service as defined in rule 
5122-29-06
 of the Administrative Code may receive any of the component services or supports listed in paragraph (C) of this rule through telehealth.
(E) At the beginning of each session, a provider is to ask the client to provide the location (e.g., street address and city) where the client is currently receiving services or supports and update the address whenever the client site changes.
(F) All certifiable services or supports provided by telehealth are to:
(1) Begin with the verification of the client through a name and password or personal identification number; and
(2) Be provided in accordance with all state and federal laws including those pertaining to the protection of patient information. Accordingly, a provider is to ensure that any username or password information and any electronic communications between the provider and client are securely transmitted and stored.
(G) A provider's physical site is to conform to the standards in rule 
5122-25-02
 of the Administrative Code.

Last updated August 3, 2026 at 8:36 AM

Supplemental Information

Authorized By:

R.C. 
5119.36

Amplifies:

R.C. 
5119.36

Five Year Review Date:

8/1/2031

Prior Effective Dates:

11/21/2020