Montana State Hospital
Policy Manual -- Volume I
Table of Contents
August 1, 2006
Policy # |
Description |
Last Issue Date |
|
Section I -- Admission and Discharge |
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| Admission Policy for Montana State Hospital | #AD-01 | Establishes criteria and procedures for admission to MSH | 05/02/2005 |
| Discharge From Hospital | #AD-02 | Establishes procedures for the release of patients from the hospital. | 08/22/2006 |
| Discharge Planning | #AD-04 | Discharge planning procedures to ensure that discharge planning begins at the time of admission and is updated throughout the duration of hospitalization. | 08/28/2006 |
| Interstate Compact on Mental Health | #AD-05 | Specifies responsibilities for the admission and transfer of patients to and from out-of-state mental health facilities under the provisions of the interstate compact on mental health. | 09/08/2003 |
| Management of Patient's Personal Effects | #AD-03 | MSH responsibility for safekeeping of patient's personal effects | 06/07/2003 |
| Pre-Placement Visit | #AD-06 | To establish procedures between MSH and community providers for pre-placement visits and pre-placement visits with subsequent discharges. | 02/16/2007 |
| Temporary Leave to Court Custody | #AD-07 | To provide for temporary release of a patient for court proceedings. | 01/14/2008 |
Section II -- Administration |
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| Centralized Contracting | #ADM-01 | Procedures for managing contracted services | 05/02/2008 |
| Description of Services | #ADM-05 | Defines MSH's role in providing psychiatric services. | 08/28/2006 |
| Firearms Carried by Law Enforcement Officials | #ADM-02 | Prohibits law enforcement officers from carrying fire arms into patient occupied buildings | 06/04/2007 |
| Governance | #ADM-09 | Identifies responsibilities for governance, management, and control of Montana State Hospital | 08/28/2006 |
| Nondiscrimination Policy | #ADM-06 | Prohibits discriminatory treatment practice | 06/04/2007 |
| Patient Visitor Housing | #ADM-03 | Provides an on-campus housing unit for family members visiting patients | 06/08/2007 |
| Parking Policy | #ADM-11 | To outline procedures for employee, visitor, and handicap parking on the Montana State Hospital campus | 07/01/2007 |
| Pharmaceutical Industry Representatives | #ADM-10 | To establish guidelines for interactions between staff of Montana State Hospital and Pharmaceutical Industry Representatives | 04/06/2007 |
| Policy Development, Revision, Format, Approval, and Distribution | #ADM-04 | Describes procedure for development, approval, and dissemination of hospital policy/procedure | 06/08/2007 |
| Tobacco Use | #ADM-07 | Defines limited use of tobacco by MSH patients, and restricted use by staff and visitors | 10/13/2005 |
| Visitors | #ADM-08 | Establishes procedures and hours for visiting patients | 06/04/2004 |
Section III -- Business Services |
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| Disposition of State Property | #BS-01 | Procedures regarding the disposition on non-expendable state property | 11/17/2004 |
| Front Desk Change Fund | #BS-07 | Establishes procedures for the front desk change fund for use in the sale of visitor meal tickets. | 11/17/2004 |
| Imprest Cash Account | #BS-02 | Procedures for the operation of the Imprest Cash Account (petty cash fund) | 11/17/2004 |
| Interagency Charges for Photocopies | #BS-06 | DPHHS agencies utilizing MSH copy machines will be charged an established and reasonable fee per copy. | 05/02/2005 |
| Operation of Patient Deposit | #BS-03 | Procedure for the operation of the Patient Deposit Office | 11/17/2004 |
| Patient Travel | #BS-04 | Procedure for providing funds for bus or airline tickets for patients | 11/17/2004 |
| Reimbursement for Damage/Destruction of Hospital Property | #BS-05 | An organized procedure to provide reimbursement for the destruction or damage of hospital property. | 11/17/2004 |
| Residents Council Incentive Program | #BS-08 | Policy and procedure for the use of monetary incentive by the Montana State Hospital Residents Council | 11/17/2004 |
| Revolving Cash Checking (Contingency) Account | #BS-09 | Policy and procedure under which a Contingency Check is to be utilized in lieu of a Pay Voucher. |
11/17/2004 |
| Employee Charges for Photocopies | #BS-10 | To ensure photocopy expenses incurred at MSH are paid. | 05/02/2005 |
| transitional Funds - requests and Approval | #BS-11 | To provide procedures for requesting and authorizing funds for the purpose of assisting people in transitioning from Hospital care to community placements. | 05/03/2007 |
Section IV -- Commitment/Recommitment Petitions |
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| Petitions for Commitment/Recommitment, and Receiving and Recording Hearings/Orders | #CP-01 | Procedure for filing commitment or recommitment petitions | 05/02/2005 |
Section V -- Dental Services |
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| Anesthesia Use in Dental Procedures | #DL-01 | Procedures for administration of anesthesia for dental procedures | 05/09/2008 |
| Dental Records | #DL-02 | Procedures for maintaining dental records | 05/09/2008 |
| Dental Services | #DL-03 | Procedures for the provision of routing and emergency dental services for MSH patients | 05/09/2008 |
Section VI -- Dietary Services |
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| Clinical Nutrition Services | #DS-01 | Procedures for ordering special diets and food supplements; describes dietary assessment procedures | 06/30/2003 |
| Food-Drug Interactions | #DS-02 | Procedure to inform patients of drug-food interactions which require dietary modifications | 05/20/2002 |
| Provision of Dietary Services | #DS-03 | Guidelines for meal distribution, and special event meal/snack service | 05/20/2002 |
Section VII -- Emergency Response |
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| Allegation of Rape or Sexual Assualt | #ER-01 | Procedures of action to take when a patient makes an allegation of rape | 05/02/2005 |
| Fire, Emergency, and Disaster Plan | #ER-02 | Establishment of Fire, Emergency, and Disaster Plan, and communication of information to employees | 05/02/2008 |
| Missing Patients -- Unauthorized Leave | #ER-03 | Procedures regarding patients who leave the hospital without authorization, including notification process | 01/14/2008 |
| Response and Notification of Authorities in the Event of a Serious Emergency | #ER-04 | Establishes response procedures in the event of serious emergencies (eg, unusual or unnatural deaths, serious injuries, rape, assault, suicide, homicide) | 05/02/2005 |
Section VIII -- Forensic Program |
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| Forensic Review Board | #FP-01 | Responsibilities and operations of the Forensic Review Board | 01/28/2002 |
| Good-Time Award for Sentenced Patients | #FP-02 | Elimination of Good-Time Awards for patients on Forensic Sentences and retention of time earned under previous policy | 05/02/2005 |
| Security restraints for patients on forensic commitments | #FP-03 | To provide for safety and security when escorting patients who present a serious risk to the public and who are committed to the hospital through criminal proceedings (forensic commitments). | 08/01/2006 |
| Forensic (D Unit) Security Procedures | #FP-04 | To provide for security procedures specific to the Forensic Unit (D Unit) of Montana State Hospital | 01/02/2008 |
Section IX -- Health Information |
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| Abbreviations | #HI-01 | List of approved abbreviations | 05/21/2007 |
| Billing Charges for Photocopies of Health Information | #HI-02 | Establishes procedures for charging for copies of medical records | 05/02/2005 |
| Charting Rules to Observe | #HI-03 | General rules for charting | 09/01/2002 |
| Discharge Summary | #HI-04 | Guidelines for completion of Discharge Summaries | 09/02/2007 |
| Documentation in Progress Notes | #HI-05 | Progress Note entries | 09/01/2002 |
| Employee Access to Protected Health Information | #HI-14 | Addresses MSH employee access to various levels of Protected Health Information (PHI) as necessary to conduct their work | 06/06/2003 |
| Employee Sanctions for Releases of Protected Health Information | #HI-15 | Addresses disciplinary action to be taken toward MSH employees who release PHI in violation of HIPAA Privacy Rules and DPHHS/MSH policies. | 06/06/2003 |
| Guidelines for Release of Information | #HI-06 | Procedures for releasing information from medical records | 09/01/2002 |
| HIPPA Documentation and Record Retention | #HI-18 | Addresses documentation and record retention requirements
of the Health Insurance Portability and Accountability Act of 1996. |
08/01/2003 |
| Medical Records: Access and Security | #HI-07 | Procedures to control access to medical records and maintain security | 09/01/2002 |
| Medical Records: Facsimile Transmission | #HI-08 | Procedures governing sending and receiving medical records information via facsimile (fax) machine | 09/01/2002 |
| Mental Disabilities Board of Visitors -- Access to Patient Records | #HI-09 | Access to patient records by Board of Visitors staff | 09/01/2002 |
| Montana Advocacy Program (MAP) -- Access to Patient Records | #HI-10 | Access to patient records by staff of the Montana Advocacy Program | 09/01/2002 |
| Notice of Privacy Practices | #HI-16 | Information that must be contained in the official notice of privacy practices titled "Notice of Use of Private Health Information." | 07/01/2003 |
| Patient Request to See, Copy, and/or Amend His/Her Own Chart | #HI-11 | Procedures for handling patient requests to see or amend their clinical record | 09/01/2002 |
| Record Retention and Storage | #HI-12 | Record retention procedures | 09/01/2002 |
| Records of Persons Admitted on Emergency Detention or Court Ordered Detention Status | #HI-13 | Identifies essential information to be entered into the medical record for emergency detention or court ordered admissions | 09/01/2002 |
Section X -- Housekeeping/Laundry |
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| Housekeeping Chemicals and Their Safe Use | #HL-01 | Procedures for use of chemical cleaning compounds | 11/17/2004 |
| Terminal Isolation Room Cleaning | #HL-02 | Cleaning of isolation rooms | 05/02/2005 |
Section XI -- Human Resources |
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| Access Control Keys | #HR-01 | Ensures appropriate access to all hospital areas | 08/28/2006 |
| Assignment of Utilization of Personnel | #HR-02 | Prohibits assignment of personnel based on gender | 08/28/2006 |
| Attendance & Work Hours | #HR-18 | Delineates length of work hours and break periods | 08/28/2006 |
| Borrowing of Hospital Supplies and/or Equipment | #HR-04 | Prohibits loaning of MSH supplies or equipment to employees, groups, or community agencies for personal use | 08/28/2006 |
| Code of Ethics for Employees of Montana State Hospital | #HR-05 | Employee ethics policy | 08/28/2006 |
| Department of Public Health & Human Services Personnel Policies | #HR-20 | To ensure applicable guidelines are avialbe to administrative and supervisory staff for use when resolving personnel issues. | 08/28/2006 |
| Dress Code Standards | #HR-07 | Employee dress code | 07/19/2007 |
| Drug and Alcohol Testing Policy for Employees Holding a Commercial Driver's License | #HR-08 | Procedure for complying with state and federal regulations regarding drug and alcohol testing of employees | 08/28/2006 |
| Employee Conduct | #HR-06 | Rules of conduct for employees | 08/28/2006 |
| Employee Identification | #HR-23 | Specifies requirements for employee identification through the use of identification badges. | 06/08/2007 |
| Employee Recreation | #HR-09 | Establishes rules for employee use of the hospital's recreation facilities | 09/01/2002 |
| Housing Policy | #HR-10 | Policy regarding the management of employee housing units | 08/28/2006 |
| Leave Policy | #HR-03 | Use of different types of Leave (eg sick leave, annual leave) | 08/28/2006 |
| On-Call Positions | #HR-11 | Establishes on-call staffing pool | 08/28/2006 |
| Performance Planning and Evaluation | #HR-12 | Employee performance planning and evaluations | 11/17/2004 |
| Physician and Licensed Prescriber Housing | #HR-22 | Policy requiring physicians and other licensed prescribers participating in the on-call rotation to maintain on-campus housing. | 08/28/2006 |
| Probation/Trial Period | #HR-14 | Designates probationary periods for employment | 08/28/2006 |
| Reimbursement for Damaged Employee Owned Property | #HR-13 | Limits MSH liability for loss or theft of personally owned articles | 08/01/2007 |
| Sexual Harassment | #HR-15 | Procedures for handling allegations of sexual harassment | 08/30/2006 |
| Sick Leave Abuse | #HR-16 | Defines abuse of sick leave and disciplinary procedures | 08/28/2006 |
| Verification of Licensure/Certification | #HR-17 | Procedures to ensure verification of licensure and certification for appropriate hospital employees | 08/28/2006 |
| Volunteers | #HR-19 | Establishes procedures for volunteers working at MSH | 08/28/2006 |
| Workplace Violence and Harassment Prohibited | #HR-21 | Procedures and guidelines adderssing occurrences of workplace violence and harassment | 08/28/2006 |
Page last updated: 05/09/2008
