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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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Chapter5122-27. Minimum Requirements for Integrated Clinical Records |
5122-27-01. Applicability
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(A) The provisions of the rules contained in this chapter are applicable to each provider:
(1) Providing mental health and addiction services that are funded by, or funding is being sought from:
(a) A board of alcohol, drug addiction, and mental health services.
(b) Federal or department block grant funding for certified services.
Any service contact provided by a provider that is paid for in whole or in part by any community mental health board of alcohol, drug addiction, and mental health service or federal or department block grant funding shall be subject to the provisions of this chapter.
(2) Providing the following addiction treatment services, regardless of payor source:
(a) Residential and withdrawal management substance use disorder services provided in a setting other than an acute care hospital;
(b) Addiction services provided in a residential treatment setting;
(c) Addiction services provided on an outpatient basis, including one or more of the following addiction services provided on an outpatient basis:
(i) General services.
(ii) Crisis intervention service.
(iii) Peer recovery services.
(iv) SUD case management services.
This paragraph does not apply to either of the following:
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 the services described in paragraphs (A)(2)(a) to (A)(2)(c) of this rule, regardless of whether the services are performed as part of a sole proprietorship, partnership, or group practice;
An individual who provides the services described in paragraphs (A((2)(a) to (A)(2)(c) of this rule 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 mental health and addiction services.
(3) Subject to department certification as a driver intervention program according to section 5119.38 of the Revised Code.
(4) That voluntarily request certification.
(5) Is seeking licensure as an opioid treatment program in accordance with Chapter 5122-40 of the Administrative Code.
(B) These rules do not diminish or enhance the authority of boards of alcohol, drug addiction, and mental health services to administer the community mental health or addiction treatment system pursuant to the Ohio Revised Code, and applicable federal law.
(C) The provisions of the rules contained in this chapter are applicable to all services certified by the department; except for the following services and where specifically exempted:
(1) 5122-29-07 Forensic evaluation service;
(2) 5122-29-08 Behavioral health hotline service;
(3) 5122-29-12 Driver intervention program;
(4) 5122-29-15 Peer recovery services;
(5) 5122-29-16 Peer run organization;
(6) 5122-29-19 Consultation service;
(7) 5122-29-20 Prevention service;
(8) 5122-29-22 Referral and information service; and,
(9) 5122-29-27 Supplemental behavioral health services.
(D) Additional requirements for individual client records (ICR) may be specified in Chapter 5122-26 or Chapter 5122-29 of the Administrative Code.
(E) Modified requirements for record keeping apply to the following services:
(1) Behavioral health hotline service shall maintain a log of all telephone calls including but not limited to the following information:
(a) Reason for call;
(b) Presenting problem;
(c) Disposition and/or referral(s) made;
(d) Date, time and person receiving call; and
(e) Name of caller, if given.
(2) Forensic evaluation service shall maintain records according to rule 5122-29-07 of the Administrative Code, including the requirement to:
(a) Provide a written summary of the forensic evaluation to the court or adult parole authority; and
(b) Store reports of forensic evaluations and any related records separately from records of persons served in other services.
(3) Prevention services. Each provider shall maintain documentation for prevention services provided, which shall be documented per occurrence, and shall include, at a minimum, the following:
(a) Date the prevention service was provided.
(b) Location where the prevention service was provided.
(c) Approximate number of consumers who received the prevention service.
(d) Types of prevention strategies/services provided.
(e) Description of activities conducted.
(f) Signature of an individual who is qualified to provide prevention services in accordance with rule 5122-29-20 of the Administrative Code.
(4) Medical activities provided as part of general services pursuant to rule 5122-29-03 of the Administrative Code shall be shall be documented by progress notation, documentation of issuing a prescription, or review of test results .