Ohio Admin. Code 5122-14-03 - Licensure procedure

(A) An inpatient psychiatric service provider wishing to establish inpatient services for the first time for persons with mental disorders shall will, prior to occupancy and provision of services, make application for full licensure to the department.

(1) The At a minimum, an application shall is to consist of, at minimum all of the following:

(a) Completed A completed application form;

(b) Approved An approved building inspection or certificate of occupancy report;

(c) Approved An approved fire inspection report;

(d) Non-refundable A non-refundable annual licensure fee;

(e) Reduced A reduced line drawing showing the location and function of all patient and staff areas including the floor and social space square footage;

(f) Comprehensive A comprehensive plan of service;

(g) Proof Before September 30, 2024, and only if applicable, proof of psychiatric bed registration as reported annually to the Ohio department of health, as applicable;

(h) Verification of current TJC, HFAP ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation;

(i) Completed A completed self-survey checklist; and

(j) Statement A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age, and the number of licensed beds designated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older shall is to equal the total number of licensed beds for the inpatient psychiatric service provider. ; and

(k) If applicable, the notification required by section 5119.334 of the Revised Code.

(2) The proposed inpatient psychiatric service provider shall will be subject to an on-site inspection by a designee of the department prior to occupancy to determine if the inpatient psychiatric service provider is in compliance with section 5119.33 of the Revised Code and the rules in this chapter.

(3) An interim license not to exceed ninety days may be issued to the inpatient psychiatric service provider upon completion and departmental approval of the requirements stated mandates specified in paragraphs (A)(1) to and (A)(2) of this rule.

(4) Prior to expiration of the interim license, the department may issue a full license based on review and approval by the department of both of the following:

(a) Implementation of policies and procedures; and

(b) Documentation of being in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter.

(B) For an inpatient psychiatric service provider holding a current license, annual renewal of full licensure shall will be based on receipt and approval by the department of all of the following:

(1) Completed A completed application form which that assures that the private inpatient psychiatric service provider remains in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter;

(2) All Documentation of the substantial changes in written policies and procedures the provider has made during the current licensure period specific to the inpatient psychiatric service provider treatment and licensure rules in this chapter to be submitted to the department when the inpatient psychiatric service provider does not receive an on-site survey;

(3) Approved An approved fire inspection report, dated within one year of licensure renewal date;

(4) Approved An approved building inspection report, if renovations or major changes in the building have been made, or a major change has been made in the use of space;

(5) Non-refundable The non-refundable annual licensure fee;

(6) Statement A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age, and the number of licensed beds dedicated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older shall is to equal the total number of licensed beds for the inpatient psychiatric service provider;

(7) Verification of current TJC, HFAP ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation; and

(8) A thirty-day notice shall be given whenever possible by the department to the inpatient psychiatric service provider prior to the expiration of the annual license If applicable, the notification required by section 5119.334 of the Revised Code.

The department will issue automated notices from the licensure and certification tracking system (LACTS) to the inpatient psychiatric service provider prior to the expiration of the annual license

(C) Renewal of full licensure shall require an on-site survey of the inpatient psychiatric service provider every three years, or as determined by the department, to be conducted by a designee of the department to assure A designee of the department will conduct an on-site survey of the inpatient psychiatric service provider every three years to ensure compliance with licensure section 5119.33 of the Revised Code and the rules in this chapter. A thirty-day Whenever possible, the department will give the inpatient psychiatric service provider notice shall be given whenever possible by the department to the inpatient psychiatric service provider prior to such a at least thirty days before the survey is to occur.

(D) The department shall will provide to an inpatient psychiatric service provider a written communication identifying any deficiencies or non-compliance with licensure rules in this chapter subsequent to an on-site survey, or whenever the inpatient psychiatric service provider is found to be in non-compliance with such rules.

(1) If deficiencies or non-compliance with such rules are present, the inpatient psychiatric service provider shall is to submit documentation of its corrective actions as specified by the department in its written report.

(2) When the deficiencies have been corrected, or a plan to do so has been received and granted approval by the department, the department may then issue a full or probationary license. The existing license shall is to remain in effect until the department grants a full, probationary, or interim license, or rescinds the license in accordance with provisions of Chapter 119. of the Revised Code.

(3) The inpatient psychiatric service provider shall is to fully implement its plan of correction within the timeframes specified by the department.

(E) A license shall will be issued to a specific inpatient psychiatric service provider for a specified total maximum daily census expressed as licensed beds, and may is not to be transferred, modified, or changed without prior approval from the department.

(1) Licensed Before September 30, 2024, licensed beds shall are to be registered annually with the Ohio department of health, pursuant to section 3701.07 of the Revised Code.

(2) Any Before making any change in the location or the total number of licensed beds shall require prior , the licensee is to seek approval from the department.

(3) The number of licensed beds shall refer refers to the actual number of set up and staffed beds available for immediate patient occupancy, or which that can be made available for patient occupancy within twenty-four hours.

(a) If an inpatient psychiatric service provider has temporarily designated patient bed space for other purposes to best meet space allocation needs, or if beds have been unavailable for occupancy due to renovation of the psychiatric hospital's hospital or inpatient unit(s)' unit physical facilities, these beds once available for patient occupancy may be licensed (once available for patient occupancy) upon application by the inpatient psychiatric service provider to the department.

(b) The Before September 30, 2024, the total number of licensed beds shall is not to exceed the number of beds registered with the department of health pursuant to section 3701.07 of the Revised Code.

(4) If an inpatient psychiatric service provider wishes to cease provision of inpatient services, it shall is to notify the department in writing so that its license can be terminated. The inpatient psychiatric service provider shall is to also notify the department of health, as applicable.

(F) An inpatient psychiatric service provider may be visited at any time by a designee of the department to determine compliance with rules in this chapter. The department is to have access to, and may have copies of, any of the provider's records, regardless of format, to verify compliance with section 5119.33 of the Revised Code and the rules in this chapter. In addition, the department may conduct interviews with members of the provider's governing body, staff, and others and, with patient permission, a patient.

Notes

Ohio Admin. Code 5122-14-03

Effective: 4/24/2024
Five Year Review (FYR) Dates: 1/19/2024 and 04/24/2029
Promulgated Under: 119.03
Statutory Authority: R.C. 5119.33
Rule Amplifies: R.C. 5119.33
Prior Effective Dates: 10/12/1978, 01/01/1991, 01/01/2000, 07/01/2011, 02/17/2017