Ohio Administrative Code › Title 5122 - Department of Mental Health and Addiction Services › Chapter 5122-14 - Licensing of Psychiatric Hospitals and Units › Section 5122-14-01 - Definitions and applicability

Current through all regulations passed and filed through July 1, 2024
(A) The provisions of Chapter 5122-14 of the
			 Administrative Code apply to each inpatient psychiatric service provider
			 licensed pursuant to section
			 5119.33 of the Revised Code by
			 the department of mental health and addiction services.
(B)
			 The following definitions  apply to
			 Chapter 5122-14 of the Administrative Code:
(1) "Abuse" means any act or absence of
			 action caused by an employee inconsistent with rights
			 that
			 results in or could result in physical injury to
			 a patient; any act that constitutes sexual activity, as defined under
			 Chapter 2907. of the Revised Code, when such activity would constitute an
			 offense against a patient under that chapter;
			 insulting or coarse language or gestures directed toward a patient
			 that
			 subjects the patient to humiliation or degradation; or depriving a patient of
			 real or personal property by fraudulent or illegal means.
(2)
									"Abused child" has the same meaning as in section
			 2151.031 of the Revised
			 Code.
(3)
									"ACHC" means the accreditation commission for health
			 care.
(4)
									"Admission" means acceptance by the inpatient
			 psychiatric service provider of a person with the intent of providing at least
			 twenty-four hours continuous care and treatment to that person.
(5)
			 "Advance directives" means a legal document an adult can use to direct in
			 advance the decisions about their mental or physical health treatment if in the future they lack the capacity to make
			 their own health care decisions.
(6) "Certified nurse
			 practitioner" has the same meaning as in
			 section 4723.01 of the Revised
			 Code.
(7) "Chemical
			 restraint" means any medication that alters the functioning of the central
			 nervous system in a manner that limits physical and cognitive functioning to
			 the degree that the patient cannot attain the patient's highest practicable
			 physical, mental, and psychosocial well-being.
(8) "Child and
			 adolescent psychiatrist" means a psychiatrist who is certified in child and
			 adolescent psychiatry by the American board of psychiatry and neurology or has
			 successfully completed training in a child and adolescent psychiatry program
			 approved by the residency review committee of the accreditation council for
			 graduate medical education of the American medical association. A child and
			 adolescent psychiatrist is also a psychiatrist as defined in this
			 rule.
(9) "Clear treatment
			 reasons" means that a patient would present a substantial risk of physical harm
			 to themselves or others, or that effective treatment of the patient would be
			 substantially precluded.
(10) "Clinical nurse
			 specialist" has the same
			 meaning as in section
			 4723.01 of the Revised
			 Code.
(11) "Clinical
			 privileges" means authorization granted to a practitioner to provide specific
			 health care services in the organization within well-defined limits, based on
			 the following factors, as applicable: license, certification, registration,
			 education, training, experience, competence, health status, and
			 judgment.
(12) "CMS" means the
			 centers for medicare and medicaid services, a federal agency within the U.S.
			 department of health and human services.
(13)
			 "Community addiction services provider" has the same meaning as in section
			 
									5119.01 of the Revised
			 Code.
(14) "Community mental
			 health services provider" has the same meaning as in
			 section 
									5119.01 of the Revised
			 Code.
(15) "Counselor" means
			 an individual who is licensed as a professional counselor or a professional
			 clinical counselor in accordance with Chapter 4757. of the Revised
			 Code.
(16) "Cultural
			 sensitivity" means an awareness, understanding, and responsiveness to the
			 beliefs, values, customs, and institutions (family, religious, etc.) of a group
			 of people, particularly those of a race or ethnic group different from one's
			 own, or those identified cultures of persons with specific disabilities such as
			 deafness.
(17) "Culturally
			 relevant" means incorporating awareness, understanding, and responsiveness to
			 the beliefs, values, customs, and institutions (family, religious, etc.) and
			 ethnic heritage of individuals or those identified cultures of persons with
			 specific disabilities such as deafness, into training, treatment, and services
			 designed to impact upon, or meet the needs of individuals or groups.
(18)
			 "Department" means the Ohio department of mental health and addiction
			 services.
(19) "Det norske
			 veritas (DNV) healthcare, inc." means the organization, a division of det
			 norske veritas, which operates the national integrated accreditation for
			 healthcare organizations program.
(20) "Developmental
			 disability" has the same meaning as in
			 section 5123.01 of the Revised
			 Code.
(21) "Director" means
			 the director of the Ohio department of mental health and addiction
			 services.
(22) "Dietitian" means
			 an individual who is licensed as a dietitian in accordance
			 with Chapter 4759. of the Revised Code.
(23) "Emergency" means
			 an impending or crisis situation that creates circumstances demanding immediate
			 action.
(24) "Expressive
			 therapist" means an individual who provides treatment intervention through the
			 use of such activities as art, music, or
			 dance
									and
			 who (a) is certified or registered by the
			 national expressive therapist association, certification board for music
			 therapists, American arts therapy association, American dance therapy
			 association or (b) is licensed, certified or registered by another
			 recognized state or national body to practice expressive therapy.
(25)
			 "Family members" means persons related by family to a patient.
(26)
			 "Grievance" means a written record of  dissatisfaction with mental
			 health servicesexpressed by a patient, family member, significant
			 other, patient rights advocate, or other interested person or agency.
(27)
			 "Guardian" means any person, association, or corporation appointed by the
			 probate court to have responsibility for the care and management of a minor or
			 a person declared incompetent in accordance with Chapter 2111. of the Revised
			 Code.
(28) "Incident" means any event that poses a
			 danger to the health and safety of patients, staff, or visitors of the
			 hospital, and is not consistent with routine care of persons served or routine
			 operation of the hospital.
(29)
			 "Informed consent" means the voluntary, knowing, reasoned choice of a person,
			 or, as appropriate, the person's legal guardian to a proposed treatment or
			 procedure.
(30) "Inpatient
			 psychiatric service provider" or "hospital" means
			 a psychiatric hospital or psychiatric
			 inpatient unit administered by a general hospital, community mental health
			 service provider, or other facility that
			 provides inpatient psychiatric services.
(31) "Involuntary" means against an
			 individual's will or without having been provided informed consent.
(32) "Joint commission" (TJC) means the joint
			 commission, formerly known as the joint commission on accreditation of
			 healthcare organizations (JCAHO).
(33) "License" means the department's written
			 approval and authorization for an inpatient psychiatric service provider to
			 receive persons with a mental disorder for care and treatment.
(34) "Licensed practical nurse"
			 has the same
			 meaning as in section
			 4723.01 of the Revised
			 Code.
(35)
									"Mechanical restraint," "physical restraint," and "prone
			 restraint" have the same meanings as in rule
			 5122-26-16 of the Administrative
			 Code.
(36) "Medical record"
			 means the account of a patient's hospitalization, compiled by health care
			 professionals, including but not limited to a patient's history, present
			 illness, findings on examination, details of care, services and treatment, and
			 progress notes.
(37) "Medication"
			 means therapeutic drugs (or agents or compounds) dispensed,
			 personally furnished, or administered pursuant to a prescription or order
			 by an appropriately licensed independent practitioner.
(38) "Neglect" means a purposeful
			 or negligent disregard of duty imposed on an employee or staff member by
			 statute, rule, or professional standard and owed to a patient by that employee
			 or staff member.
(39) "Nursing
			 staff" means clinical nurse specialists, certified nurse practitioners, registered nurses,
			 licensed practical nurses, nursing assistants, and other nursing personnel who
			 perform patient care.
(40)
			 "Occupational therapist" has the same meaning as in section
			 4755.04 of the Revised
			 Code.
(41) "Occupational therapy
			 assistant" has the same meaning as in section
			 4755.04 of the Revised
			 Code.
(42) "Patient" means a person
			 admitted to a hospital or inpatient unit either voluntarily or involuntarily
			 who is under observation or receiving treatment or is receiving any other mental health services
			 by the inpatient psychiatric service provider.
(43) "Patient rights specialist" means
			 a
			 person designated by each inpatient psychiatric service provider to
			 safeguard patient rights and to assist patients in exercising their rights,
			 including the rights in this chapter and in Chapter 5122. of the Revised
			 Code.
(44) "Physician" means a
			 person authorized under Chapter 4731. of the
			 Revised Code to practice medicine
									and surgery or osteopathic medicine and surgery
			 or a medical officer of the government of the United States while in this state
			 in the performance of his or her official duties.
(45) "Psychiatric
			 intensive care" means a program within a
			 defined secure physical space
									( normally including patient lounge and sleeping
			 room space)
			 utilized to provide a more intense form of care for those patients requiring
			 closer observation, decreased environmental stimulation, or a more intensive
			 staff to patient ratio.
(46) "Psychiatrist"
			 has the same meaning as in section
			 5122.01 of the Revised
			 Code.
(47) "Psychiatrist
			 with clinical privileges in adolescent psychiatry" means a psychiatrist who is
			 qualified through training and experience specific to the needs of adolescent
			  patients and  has
			 specific hospital clinical privileges to provide treatment to adolescent
			  patients.
(48) "Psychiatrist
			 with clinical privileges in geriatric psychiatry" means a psychiatrist who is
			 qualified through the American board of psychiatry and neurology or through
			 other documented training or experience specific to the needs of geriatric
			  patients and  has
			 specific hospital clinical privileges to provide treatment to geriatric
			  patients.
(49) "Psychologist"
			 means an individual who holds a current, valid
			 license to practice
			  psychology issued under section
			 4732.12 of the Revised
			 Code.
(50) "Psychotropic
			 medication" means that group of medications having a specific and intended effect
			 on central nervous system functions that are ordinarily used to alter
			 disorders of thought, perception, mood, or behavior.
(51) "Recovery" means
			 a personal process of overcoming the negative impact of a psychiatric
			 disability despite its continued presence.
(52) "Recreational
			 therapist" means an individual who is registered by the Ohio recreational
			 therapy registration board or certified by the national council for therapeutic
			 recreation certification or
			 who is licensed, certified, or registered by another recognized state or
			 national body to practice recreational therapy.
(53) "Registered nurse
			 (R.N.)" has
			 the same meaning as in section
			 4723.01 of the Revised
			 Code.
(54) "Rehabilitation
			 therapist" means  an occupational
			 therapist,  occupational therapy
			 assistant,  recreational therapist, or
			  expressive therapist as defined in this
			 rule. Such individuals are to comply with current, applicable scope of
			 practice and supervisory requirements as identified by their appropriate
			 licensing, certifying, or registering
			 bodies.
(55) "Rehabilitation
			 therapy services" means structured activities designed to help a patient
			 develop or maintain functional living skills including physical, social, and creative skills through participation in
			 activities of daily living, vocational, recreational, social, expressive, or
			 other activities designed to promote patient recovery, resiliency, and independence in both the hospital and community
			 setting.
(56) "Reportable
			 incident" means an incident that has to be submitted to the departmentthrough the web enabled incident
			 reporting system (WEIRS), maintained by the department, in accordance with the
			 rules in this chapter. As referenced in division
			 (G) of
			 section 5119.36 of the Revised Code,
			 "major unusual incident" has the same meaning as "reportable
			 incident".
(57) "Resiliency"
			 means the personal and community qualities that enable individuals to rebound
			 from adversity, trauma, tragedy, threats, or other stresses
			  and to go on with life with a sense of
			 mastery, competence, and hope.
(58)
			 "Restraint" means any manual method, physical or mechanical device, material,
			 or equipment that immobilizes or reduces the ability of a patient to move his
			 or her arms, legs, body, or head freely.
(59)
			 "Seclusion" means the involuntary confinement of a patient alone in a room
			 where the patient is physically prevented from leaving.
(60)
			 "Significant other" means an individual who is significant and
			 important to the well-being of the patient, as identified by the
			 patient.
(61) "Social
			 worker" means a
			 person licensed under Chapter 4757. of the Revised Code
			 to practice as a social worker or independent social
			 worker.
(62) "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 restraint, mechanical restraint, or physical restraint as defined in
			 this rule. Transitional holds are not seclusion or restraint.
(63)
			 "Treatment plan" means a written statement of goals and objectives for a
			 patient with corresponding treatment interventions and services.
(64)
			 "Variance" means permission granted by the director or designee in writing to
			 an inpatient psychiatric service provider to change the conditions or specific
			 mandates of a rule.
(65) "Waiver" means
			 permission granted by the director or designee in writing to an inpatient
			 psychiatric service provider to be exempted from the conditions of specific
			 mandates of a rule.