About Licensure and Certification

AboutThe Ohio Department of Mental Health & Addiction Services has statutory and regulatory authority over providers of behavioral health services to Ohio consumers. Separate standards apply depending on the type and level of service provided. The type and level of service is organized in the following manner: Community Behavioral Health AgenciesResidential Facilities and Inpatient Psychiatric Service Providers.

Community Behavioral Health Agencies require certification by OhioMHAS when they provide mental health services that are funded by a community mental health board or when they are subject to department licensure of a residential facility according to section 5119.22 of the Revised Code. Community Mental Health Agencies may also voluntarily request certification.

Residential Facilities (non-substance use disorder (SUD)) require licensure by the department if they operate a publicly or privately operated home or facility serving an individual(s) with mental illness.

Inpatient Psychiatric Service Providers require licensure if they are private psychiatric hospitals providing acute inpatient mental health services.

Information explaining some of the office functions, as well as requirements is included below. For a more detailed explanation of the rules and processes involved in Certification and/or Licensure, a provider interested in obtaining Certification and/or Licensure is encouraged to read the applicable rules.

Bureau of Licensure

Purpose - Authoritative Charge 

The Ohio Department of Mental Health & Addiction Services (OhioMHAS) has statutory and regulatory authority over providers of behavioral health services for Ohio consumers. Separate standards apply depending upon the type and level of service provided. The type and level of service is organized in the following manner: Community Behavioral Health Agencies (substance use disorder and/or mental health including prevention services), Driver Intervention Programs, Opioid Treatment Programs, Residential Facilities and Private Inpatient Psychiatric Service Providers. 

Community Behavioral Health Agencies require certification by OhioMHAS when they provide services that are funded by the Ohio Medicaid program for community mental health or addiction services, a county community mental health and addiction treatment services board, or federal or state block grant funding, are applying for licensure as an Opioid Treatment Program, provide a driver intervention program, or when they are subject to department licensure as a Class One residential facility according to section 5119.34 of the Revised Code. Community Behavioral Health Agencies may also voluntarily request certification. 

Effective 9/29/19 in accordance with Ohio Revised Code 5119.35, certain agencies* cannot provide one or more of the following addiction treatment services unless it has first obtained certification: residential and/or withdrawal management substance use disorder services unless provided in an acute care hospital; one or more of the following outpatient addiction services unless provided in an accredited hospital’s outpatient clinic: General services; Crisis intervention service; Peer recovery services; and SUD case management services. 

*The requirement for certification does not apply to 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, regardless of whether the services are performed as part of a sole proprietorship, partnership, or group practice or 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.

Residential Facilities (non-substance use disorder (SUD)) require licensure by the department if they operate a publicly or privately-operated home or facility serving an individual(s) in one of these classes: 

Class 1 – owned/operated by a Behavioral Health Provider: provide accommodations, supervision, personal care services, and mental health services for one or more unrelated adults with mental illness or one or more unrelated children or adolescents with severe emotional disturbances. 

Class 2 – provides accommodations, supervision, and personal care services to any of the following: 

  • One or two unrelated persons with mental illness; 
  • One or two unrelated adults who are receiving residential state supplement payments; or, 
  • Three to sixteen unrelated adults. 

Class 3 – provides room and board for five or more unrelated adults with mental illness. 

Inpatient Psychiatric Service Providers require licensure if they are private psychiatric hospitals providing acute inpatient mental health services.

Bureau of Licensure and Certification

The Bureau of Licensure & Certification performs a variety of routine and “for cause” regulatory activities.

Regulatory activities include on-site surveys, inspections and reviews to determine compliance with the applicable administrative rules. Providers are certified every three years, private psychiatric units/hospitals are licensed annually, residential facilities (non-SUD) are licensed every two or three years depending on Class, and Opioid Treatment Programs are licensed annually. Entities in compliance are issued a certificate and/or license to conduct specific behavioral health services and activities.

Other activities include technical assistance related to the application and survey process; maintenance of certification and licensure database; responding to and investigating complaints and concerns related to health and safety and other administrative rule violations; and following up on Private Psychiatric Hospital Incident Notification reports and Community/Residential Incident Notification reports.

Compliance Scope 

Compliance is measured against applicable Codes that govern each agency/provider that is certified or licensed to operate.

General Overview of Routine Licensure and Certification Activities 

When an application is received, the Department conducts a desk review. If the application is incomplete, the provider/facility is notified of the missing items and either provided an opportunity to submit the missing documentation or the application is returned. After the application is complete, the application is reviewed to determine whether it is compliant. If the application is non-compliant, the provider is notified of corrections needed. Once an application is determined complete and compliant following the desk review portion of the process, the Department may conduct an on-site survey if the provider is requesting certification and will conduct an on-site survey of any licensure application. Some certified surveys, such as supplemental behavioral health, do not typically require an on-site survey.

The Department conducts an entrance and exit conference at routine surveys. At each entrance conference. The purpose of the entrance conference is to officially begin the onsite review; to clarify any information or material submitted with the application for certification or licensure; answer any questions or concerns of the provider or designee; and to explain the procedures for completion of the survey. The surveys include a review of personnel records, client records, agency/provider records, and any other information requested based on the survey type. An onsite inspection of the facility, as applicable to the type of certification or license, is also conducted. At the conclusion of each on-site survey the assigned surveyor will verbally share an overview of the findings with the agency/provider at the exit conference. The surveyor will complete a written findings letter and require a Corrective Action Plan (CAP) for deficiencies found related to the required rules. The Department will approve the CAP either through a desk review or by conducting an on-site validation survey.

Initial Certification Applications 

When a provider submits an initial certification application for one or more of the following services, the Department will issue an interim certification for one hundred and eighty days: 

  • General Services [5122-29-03] 
  • Mental Health Day Treatment [5122-29-06] 
  • Residential Withdrawal Management Substance Used Disorder [5122-29-09] 
  • Crisis Intervention [5122-29-10] 
  • Employment [5122-29-11] 
  • Driver Intervention Program [5122-29-12] • SUD Case Management [5122-29-13] 
  • Peer Recovery [5122-29-15] 
  • Community Psychiatric Supportive Treatment (CPST) 5122-29-17 
  • Therapeutic Behavioral and Psychosocial Rehabilitation [5122-29-18] 
  • Prevention Services [5122-29-20] • Intensive Home-Based Treatment (IHBT) [5122-29-28] 
  • Assertive Community Treatment (ACT) 5122-29-29

Interim certification application process: 

The Department conducts the aforementioned desk review. The provider must also demonstrate clinical readiness as part of the application process if required, which is based upon the services requested to be certified. 

  • The Department may conduct an on-site inspection of the physical plant environment. 
  • After issuing an interim certificate, the Department will conduct an on-site review, typically between forty-five to ninety days after the effective date of the interim certificate, in order to review the provision of services. The Department follows the routine survey process, e.g. conduct an entrance and exit conference, and requires a Corrective Action Plan if findings of non-compliance were noted during the survey. 
  • The Department will typically either issue a full certificate, good for three years from the effective date of the interim certificate or will renew the interim if the Department is still working with the provider to correct findings noted during the interim survey. 

Mental Health and Substance Use Disorder (SUD) Services 

Certification for the services below includes both mental health and substance use services and activities. Providers who provide both mental health and substance use disorder services do not need separate certification for each service. 

General Services [5122-29-03] Consultation [5122-29-19]
Forensic evaluation service [5122-29-07] Prevention Services [5122-29-20]
Hotline [5122-29-08] Referral and Information [5122-29-22]
Crisis Intervention [5122-29-10] Supplemental Behavioral Health [5122-29-27]
Employment [5122-29-11] Intensive Home Based Treatment (IHBT) [5122-29-28]
Peer Recovery [5122-29-15] Assertive Community Treatment (ACT) [5122-29-29]
Peer Run Organization [5122-29-16]  

 

SUD Specific and Mental Health Specific Services, and Driver Intervention Program

Certification for the services below includes either Mental Health or Substance Use Disorder service, as indicated.

SUD Services 
Residential Withdrawal Management Substance Used Disorder [5122-29-09]
Driver Intervention Program [5122-29-12]
SUD Case Management [5122-29-13]
SUD Qualified Residential Treatment Program (QRTP) for Youth [5122-29-09.1]

Mental Health Services 
Mental Health Day Treatment [5122-29-06] 
Community Psychiatric Supportive Treatment (CPST) 5122-29-17 
Therapeutic Behavioral and Psychosocial Rehabilitation [5122-29-18] 
Qualified Residential Treatment Program (QRTP) for Youth [5122-30-32]

 

Client Rights

An agency applying for certification as a community behavioral health agency must develop a written Client Rights Policy and Grievance Procedure in accordance with Ohio Administrative Code Sections 5122-26-18 and 5122:2-1-02. A copy of the policy must be provided in writing and explained orally at intake or the next appointment. The rights must also be posted in locations that are visible to consumers in each building operated by the agency.