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OHIO ADMINISTRATIVE CODE ANNOTATED
5122 DEPARTMENT OF MENTAL HEALTH – ADMINISTRATION AND DIRECTOR
CHAPTER 5122-26 POLICIES AND PROCEDURES FOR THE OPERATIONS OF MENTAL HEALTH SERVICES AGENCIES
Date:
09/28/2012
Document:
5122-26-12. Environment of care and safety.
(A) The purpose of this rule is to ensure that each agency maintains a clean, safe environment which supports the provision of quality mental health services and minimizes the risk of harm to clients, staff, visitors, and others.
(B) Each agency shall designate the personnel who are responsible for implementing and oversight of the provisions of this rule.
(C) Each agency 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 agency shall 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.
(2) The agency shall evaluate and determine the need to conduct other drills, and the frequency. This shall be included in its policies and procedures.
(E) Each agency 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) Hazardous areas of the agency.
(F) The agency's policies and procedures shall include the requirement that each staff receives training during orientation on the safety procedures identified in paragraphs (C), (D) and (E) of this rule. The agency shall identify in its policies and procedures the need for on-going training on each emergency or safety procedure, and the frequency of such training.
(G) Each agency 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 agency shall develop a plan to remove the barrier.
(H) The agency shall conduct regular safety inspections at least every six months, or more often as identified by the agency'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 suppression equipment;
(6) Lighting;
(7) Food preparation areas, if applicable; and
(8) Any other areas or systems as needed and identified in agency policies and procedures.
(I) Each agency shall ensure it obtains inspections and permits in accordance with local, state or federal laws.
(1) At a minimum, the agency shall obtain the following inspections every twelve months:
(a) Fire inspection 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 agency shall ensure that it obtains inspections and/or maintains current permits as required by law, if applicable:
(a) Elevator inspection.
(b) Boiler inspection.
(c) Food service.
(d) Any other as required by local, state or federal law.
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