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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 |
5122-26-12. Environment of care and safety
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(A) The purpose of this rule is to ensure that each agency maintains a clean, safe, appropriate environment which supports the provision of quality certified services and minimizes the risk of harm to clients, staff, visitors, and others.
(B) Each provider shall designate the personnel who are responsible for implementing and oversight of the provisions of this rule. The personnel may be designated as an individual, position, or committee.
(C) Each provider shall develop written policies and procedures to address emergency situations, including:
(1) Fire, including the requirement that fire exit doors shall remain unlocked and clearly marked unless a variance has been granted by a certified authority of the division of state fire marshal of the department of commerce;
(2) Bomb threat;
(3) Natural disaster;
(4) Utility outage or malfunction, e.g. a gas leak; and
(5) Other potential threats which may be applicable based upon location, e.g. nuclear power plant leak.
(D) Each provider shall have posted evacuation plans, conduct emergency drills and evaluate the effectiveness of the drill to ascertain the need for performance improvement:
(1) Fire drills shall be conducted at least once every twelve months at each provider location offering services on a less than twenty-four hour/day basis. Residential and withdrawal management substance use disorder service providers shall conduct fire drills at least quarterly. A driver intervention program location is exempt from the provisions of this paragraph unless other services or programs are also available at the location.
(2) The provider shall evaluate and determine the need to conduct other drills, and the frequency. This shall be included in its policies and procedures.
(E) Each provider shall have written policies and procedure, which incorporate any applicable local, state or federal laws for:
(1) Safe handling, storage and disposal of hazardous materials.
(2) Safe handling and disposal of infectious waste materials, including applicable specifications of the occupational health and safety administration and the Ohio department of health.
(3) Infection control, including applicable specifications of the occupational health and safety administration and the Ohio department of health.
(4) Prohibiting the use of unvented kerosene, gas or oil heaters.
(5) Hazardous areas of the provider.
(F) The provider shall identify in its policies and procedures the need for initial and on-going training on each emergency or safety procedure, and the frequency of such training, and which staff/positions shall be required to receive each training.
(G) Each provider shall meet local, state and federal laws regarding accessibility
Whenever it identifies a structural or other barrier which limits access to or within the building, the provider shall develop a plan to remove the barrier.
(H) The provider shall conduct regular safety inspections at least every six months, or more often as identified by the provider's policies and procedure or its accrediting body. Inspections shall include attention to:
(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 inspection requirements of this paragraph.
(I) Each provider shall ensure it obtains inspections and permits in accordance with local, state or federal laws.
(1) At a minimum, the provider shall obtain the following inspections every twelve months:
(a) Approved fire inspection, which shall be free of deficiencies, by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce, to include testing of fire alarm systems.
(b) Water supply and sewage disposal inspection for facilities in which these systems are not connected with public services to certify compliance with rules of the department of health and any other state or local regulations, rules, codes or ordinances.
(2) The provider shall ensure that it obtains inspections and maintains current permits as required by law, if applicable for the following:
(a) Elevator inspection.
(b) Boiler inspection.
(c) Food service.
(d) Swimming pool.
(e) Any other as required by local, state or federal law.
Driver intervention programs provided at motels, hotels, or camps are exempt from the inspection requirements of this paragraph.
(J)
For a client assessed in need of a specialized diet, the provider shall maintain written documentation that the planning and preparation of meals is done so in accordance with a plan and instructions prepared by a physician or a dietitian licensed by the state medical board of Ohio .