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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5122 Department of Mental Health - Administration and Director |
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Chapter5122-26. Policies and Procedures for the Operation of Mental Health Services Agencies |
5122-26-06. Human resources management
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(A) The purpose of this rule is to establish that the provider's human resource management processes shall assure the provider is able to provide quality, client-driven treatment services in a safe, respectful environment.
(B) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definition shall apply to this rule:
"Personnel" means any paid or unpaid person, volunteer, contract worker, student intern or other person who is a part of an provider's workforce, including but not limited to those who perform management, clinical, operations, clerical, or other functions in support of the provider's mission, vision and goals. Contract worker does not include an individual or company with whom the provider contracts to perform occasional maintenance such as lawn care, snow removal, painting, etc. Staff or employee shall have the same meaning as personnel.
(C) The provider's human resources management policies, procedures and processes shall assure:
(1) Development of a workforce comprised of competent, qualified staff, including clinical and non-clinical staff.
(2) Appropriate and adequate supervision.
(3) Continuing education.
(4) Maintaining appropriate documentation.
(D) The provider shall develop a job description for each position that includes:
(1) Minimum qualifications for the position:
(a) Competencies, e.g. knowledge, skills and experience.
(b) Credentials and academic requirements, if applicable.
Credentials includes individuals providing services which requires being credentialed by an Ohio credentialing board and/or a federal agency, e.g. a healthcare prescriber's DEA registration.
(2) Duties and responsibilities of the position.
(E) The provider shall verify credentials, when required, prior to hire and on an on-going basis. The provider may maintain documentation of verifying credentials by making a copy of the individual's license, certificate, registration or certificate, maintaining a log noting the date and name of person who verified credentials, or by a similar method.
(F) Services to children and adolescents. Provider agencies offering services to children and adolescents shall assure:
(1) Each employee utilized in positions which are responsible for the direct care or supervision of children or adolescents shall be at least eighteen years of age.
(2) Any prospective employee, volunteer or student intern shall not have pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by a provider if the conditions as provided in paragraph (H) of rule 5101:2-5-09 of the Administrative Code have been met.
(3) Criminal record background checks on employees, volunteers and student interns are conducted by the bureau of criminal identification and investigation (BCII), or any other state or federal agency designated by the director, and, if the prospective employee does not demonstrate that they have been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI).
(G) The provider shall provide orientation training to staff and document the orientation training, which shall be completed within thirty calendar days of the first date of employment. Orientation shall include at a minimum the following:
(1) Employee and client safety.
(2) Provider's mission, vision and goals.
(3) Characteristics of the population served.
(4) Sensitivity to cultural diversity.
(5) Policies and procedures specific to job duties and responsibilities.
(6) Confidentiality, including HIPAA, and, if applicable 42 CFR part 2.
(7) Reporting abuse and neglect policies and procedures.
(8) Client rights and grievance policies and procedures.
(H) Services and supervision.
(1) All personnel for whom a state or federal credential is required by law or regulation shall maintain the current credential issued by the appropriate body in the state of Ohio and/or federal agency, and shall practice only within the scope of their credential.
(2) Services requiring supervision in accordance with Chapter 5122-29 of the Administrative Code shall be under the supervision of an individual who is eligible to supervise services as set forth in rule 5122-29-30 of the Administrative Code, and who has demonstrated experience, competency, and education in the area supervised, i.e. substance abuse, mental health or dual diagnosis.
(3) Each non-supervisor staff providing direct services shall receive regularly scheduled and documented supervision appropriate to their skill level, experience and job duties, and in accordance with the requirements of their license, certificate or registration, if applicable.
Supervision may be provided in individual and group sessions, including supervisor participation in treatment plan meetings.
(I) Continuing education and training.
(1) The provider shall assure direct service and supervisory staff participate in continuing education and training.
(a) Minimum training hours shall be in accordance with each individual's credentialing board, or
(b) Staff providing or supervising services for which no credential issued by a state credentialing board is required shall complete at least twenty hours of continuing education every two years, based on the individual's date of hire. If the individual was originally hired in a position in which he/ she was not required to participate in staff development training, but was later hired in such a position, the first twenty hours of training shall be completed within two years of the first date of work in the new position. Staff employed as of the effective date of this rule providing or supervising services for which no credential issued by a state credentialing board is required shall complete the required training within three years of the effective date, and every two years thereafter, based upon the hire date or first date of work in the new position, as applicable.
(2) Training shall:
(a) Maintain or increase competency;
(b) Include topics specific to population served; and
(c) Ensure culturally competent provision of service.
(J) Performance evaluation.
(1) The provide shall evaluate staff performance at a frequency required by its accrediting body, if applicable, or for a provider without behavioral health accreditation, annually.
(2) The provider shall establish in writing a system and frequency for evaluating volunteers, based on job duties, scope of responsibility, and frequency of service.
(3) The provider shall evaluate contract staff performance in accordance with its human resources management policies and procedures.
(K) Personnel files. The provider shall maintain a personnel file for each employee, including contract staff and volunteers. Personnel files shall be stored in such a manner as to maintain the privacy of each staff person. Provider policies shall describe who shall have access to the various information contained within the file. Personnel files shall include the following:
(1) All staff, including contract staff, student interns and volunteers:
(a) Identifying information;
(b) Verification of credentials, as applicable:
(i) From professional regulatory boards in Ohio and federal agencies, if applicable, including either electronic verification or copies of current professional licenses, certifications, or registration; or
(ii) Documentation of competency for individuals providing direct services or supervising services for which no credential is required. Each provider shall establish the documentation necessary to verify competency.
(c) Position description. For contract staff, a copy of the contract containing duties, expectations and required qualifications is sufficient.
(d) For providers which provide alcohol and other drug services, documentation that the employee has reviewed and agreed to abide by the federal regulations on the confidentiality of alcohol and drug abuse patient records (Title 42, Code of Federal Regulations, part 2).
(e) Documentation of orientation, including documentation to reflect that the employee has received a copy of the policies and procedures identified in paragraph (G) of this rule and has agreed to abide by each of them.
(f) The criminal background check required by paragraph (F) of this rule for all staff of an agency providing services to children and adolescents.
(g) Disciplinary actions, if applicable.
(2) All staff, excluding student interns or volunteers:
(a) Notification of hire, to include start date and position.
(b) For contract staff, a copy of the contract is sufficient.
(3) All staff, excluding contract staff, student interns and volunteers:
(a) Application for employment or resume, with the exception of the executive director, CEO, president or owner.
(b) Verification of references, if required for position.
(c) Performance evaluations.
(d) Documentation of on-going training in accordance with paragraph (H) of this rule for staff who provide direct service or staff who supervise services.
(L) The provider shall develop written human resources management policies and procedures sufficient to carry out the provisions of this rule. Policies and procedures shall include at a minimum:
(1) Prohibit discrimination in employment, training, job duties, compensation, evaluation, promotion, and any other term or condition of employment based on 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 prohibited by local, state or federal laws;
(2) Describe a formal process to express and process employee grievances;
(3) Prohibit sexual harassment;
(4) Establish standards of acceptable behavioral for all employees.
(5) Termination of employment.
(6) Confidentiality, including HIPAA, and, if applicable 42 CFR part 2 if applicable.
(7) Abuse and neglect policies and procedures:
(a) Required internal and external reporting of allegations of staff neglect and abuse of persons served.
(b) Responding to allegations of staff neglect and abuse of persons served.
(8) Client rights and grievance policies and procedures as required by rule 5122-26-18 of the Administrative Code.
(9) Policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee's position.
(10) Procedures for notifying employees of changes to the policies and procedures required by this rule.
(M) A copy of the written personnel policies and procedures shall be available to each employee. Employees shall be notified of changes in personnel policies and procedures.
(N) Each provider serving children or adolescents shall have a policy which states the following:
(1) Each employee utilized in positions which are responsible for the direct care or supervision of children or adolescents shall be at least eighteen years of age.
(2) A prospective employee, volunteer or student intern shall not have pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by a provider if the conditions as provided in paragraph (H) of rule 5102:2-5-09 of the Administrative Code have been met.
(3) The provider shall require that criminal records checks on employees, volunteers and student interns be conducted by the bureau of criminal identification and investigation (BCII), or any other state or federal agency designated by the director, and, if the prospective employee does not demonstrate that they have been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI).
(O) A copy of the written personnel policies and procedures shall be available to each employee. Employees shall be notified of changes in personnel policies and procedures. The provider shall establish written procedures for notifying employees of such changes.
(P) Personnel files.
(1) The provider shall maintain a person file on each staff person, who shall have access to their own personnel file.
(2) Personnel files shall be stored in such a manner as to maintain the privacy of each staff person. Provider policies shall describe who shall have access to the various information contained within the file.
(3) Each personnel file shall include the following content:
(a) Identifying information and emergency contacts;
(b) Application for employment or resume;
(c) Verification of credentials from professional regulatory boards in Ohio, if applicable, including either electronic verifications or copies of current professional licenses, certifications, or registration;
(d) Documentation of education, experience and training;
(e) Verification of references, if required for position;
(f) Notification of hire, to include start date and position;
(g) Job or position description, to include job title and:
(i) Supervisor to whom the person holding this position is responsible.
(ii) Duties or responsibilities.
(iii) Minimum qualifications for the position (knowledge and skills).
(iv) Credentials and academic requirements, if applicable.
(v) Positions supervised by person holding this position, if applicable
(h) Compensation documentation, if applicable;
(i) For providers which provide alcohol and other drug services, documentation that the employee has reviewed and agreed to abide by the federal regulations on the confidentiality of alcohol and drug abuse patient records (Title 42, Code of Federal Regulations, part 2).
(j) Performance evaluations;
(k) Documentation of orientation;
(l) Documentation to reflect that the employee has received a copy of the policies and procedures identified in paragraph (D)(7) of this rule and has agreed to abide by each of them;
(m) Documentation of on-going training, as required by position, state law and agency policy;
(n) Commendations or awards, if applicable; and
(o) Disciplinary actions, if applicable.
(Q) The provider shall have policies and written procedures for handling cases of staff neglect and abuse of persons served, and documentation that each employee has received a copy of these policies and procedures.
(R) The provider shall have a policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee's position.