Montana State Hospital
Policy Manual -- Volume I
Table of Contents
May 1, 2013
Policy # |
Description |
Last Issue Date |
|
Section I -- Admission and Discharge |
|||
| 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. | 11/09/2009 |
| 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. | 03/14/2012 |
| 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. | 11/02/2009 |
| Management of Patient's Personal Effects | #AD-03 | MSH responsibility for safekeeping of patient's personal effects | 11/30/2012 |
| Pre-Placement Visit | #AD-06 | To establish procedures between MSH and community providers for pre-placement visits and pre-placement visits with subsequent discharges. | 02/17/2012 |
| Temporary Leave to Court Custody | #AD-07 | To provide for temporary release of a patient for court proceedings. | 08/24/2011 |
Section II -- Administration |
|||
| 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. | 09/14/09 |
| Firearms Carried by Law Enforcement Officials | #ADM-02 | Prohibits law enforcement officers from carrying fire arms into patient occupied buildings | 06/01/2010 |
| Governance | #ADM-09 | Identifies responsibilities for governance, management, and control of Montana State Hospital | 7/13/2009 |
| Nondiscrimination Policy | #ADM-06 | Prohibits discriminatory treatment practice | 03/15/2010 |
| Patient Visitor Housing | #ADM-03 | Provides an on-campus housing unit for family members visiting patients | 03/12/2009 |
| Parking Policy | #ADM-11 | To outline procedures for employee, visitor, and handicap parking on the Montana State Hospital campus | 06/01/2010 |
| Pharmaceutical Industry Representatives | #ADM-10 | To establish guidelines for interactions between staff of Montana State Hospital and Pharmaceutical Industry Representatives | 03/01/2010 |
| Policy Development, Revision, Format, Approval, and Distribution | #ADM-04 | Describes procedure for development, approval, and dissemination of hospital policy/procedure | 07/06/2012 |
#ADM-12 |
To provide guidance regarding the security camera system in Montana State Hospital facilities and the maintenance and use of records generated by the system. | 03/01/2010 | |
| Tobacco Free | #ADM-07 | Defines limited use of tobacco by MSH patients, and restricted use by staff and visitors | 01/26/2011 |
| Visitors | #ADM-08 | Establishes procedures and hours for visiting patients | 11/16/2012 |
| Access to patients and treatment areas by designated protection and advocacy system | #ADM-13 | To assure that representatives of the protection and advocacy system designated by the state of Montana | 11/16/2012 |
| Access to Patient & Treatment Areas by Mental Disabilities Board of Visitor Staff | #ADM-14 | To assure that representatives of the Mental Disabilities Board of Visitors are provided access to patients of Montana State Hospital | 11/16/2012 |
Section III -- Business Services |
|||
| Disposition of State Property | #BS-01 | Procedures regarding the disposition on non-expendable state property | 07/01/2011 |
| Front Desk Change Fund | #BS-07 | Establishes procedures for the front desk change fund for use in the sale of visitor meal tickets. | 05/02/2011 |
| Imprest Cash Account | #BS-02 | Procedures for the operation of the Imprest Cash Account (petty cash fund) | 05/02/2011 |
| Interagency Charges for Photocopies | #BS-06 | DPHHS agencies utilizing MSH copy machines will be charged an established and reasonable fee per copy. | 03/02/2012 |
| Operation of Patient Deposit | #BS-03 | Procedure for the operation of the Patient Deposit Office | 05/02/20118 |
| Patient Travel | #BS-04 | Procedure for providing funds for bus or airline tickets for patients | 12/01/2007 |
| Reimbursement for Damage/Destruction of Hospital Property | #BS-05 | An organized procedure to provide reimbursement for the destruction or damage of hospital property. | 05/03/2011 |
| 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. | 12/01/2007 |
| Employee Charges for Photocopies | #BS-10 | To ensure photocopy expenses incurred at MSH are paid. | 03/02/2012 |
| 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. | 05/03/2011 |
Section IV -- Commitment/Recommitment Petitions |
|||
| Petitions for Commitment/Recommitment, and Receiving and Recording Hearings/Orders | #CP-01 | Procedure for filing commitment or recommitment petitions | 01/20/2012 |
Section V -- Dental Services |
|||
| Anesthesia Use in Dental Procedures | #DL-01 | Procedures for administration of anesthesia for dental procedures | 03/16/2011 |
| Dental Records | #DL-02 | Procedures for maintaining dental records | 03/16/2011 |
| Dental Services | #DL-03 | Procedures for the provision of routing and emergency dental services for MSH patients | 03/16/2011 |
Section VI -- Dietary Services |
|||
| Clinical Nutrition Services | #DS-01 | Procedures for ordering special diets and food supplements; describes dietary assessment procedures | 11/09/2009 |
| Food-Drug Interactions | #DS-02 | Procedure to inform patients of drug-food interactions which require dietary modifications | 03/01/2010 |
| Provision of Dietary Services | #DS-03 | Guidelines for meal distribution, and special event meal/snack service | 02/24/2009 |
Section VII -- Emergency Response |
|||
| Allegation of Rape or Sexual Assualt | #ER-01 | Procedures of action to take when a patient makes an allegation of rape | 08/22/2008 |
| Fire, Emergency, and Disaster Plan | #ER-02 | Establishment of Fire, Emergency, and Disaster Plan, and communication of information to employees | 07/01/2011 |
| Missing Patients -- Unauthorized Leave | #ER-03 | Procedures regarding patients who leave the hospital without authorization, including notification process | 03/15/2012 |
| 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) | 03/24/2011 |
Section VIII -- Forensic Program |
|||
| D Unit Outdoor Exercise Yard and Courtyards | #FP-07 | Establishes guidelines for use of the D Unit Outdoor Exercise yard and Courtyards | 11/19/2009 |
| Response to an escape of patient(s) from D Unit | #FP-05 | Provides emergency procedures in response to an escape of a patient(s) from D Unit of Montana State Hospital. | 9/24/2009 |
| Forensic Review Board | #FP-01 | Responsibilities and operations of the Forensic Review Board | 02/28/2011 |
| Forensic Involuntary Medication | #FP-08 | To define the circumstances under which forensic patients adjudicated Guilty but Mentally Ill (GBMI) or Not Guilty due to Mental Illness (NGMI) may be administered involuntary medications, and to define the administrative review process under which Montana State Hospital may authorize involuntary medications. | 02/22/2011 |
| Patient Riot - Emergency Response to D Unit | #FP-06 | To specify emergency procedures to be followed in the event of a patient riot on D Unit (forensic) of Montana State Hospital. | 9/24/2009 |
| 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). | 7/13/2009 |
| 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 |
|||
| Abbreviations | #HI-01 | List of approved abbreviations | 05/16/2011 |
| Billing Charges for Photocopies of Health Information | #HI-02 | Establishes procedures for charging for copies of medical records | 07/29/2011 |
| Charting Rules to Observe | #HI-03 | General rules for charting | 11/09/2009 |
| Access to Patient Records by Protection and Advocacy System ( | #HI-10 | To establish procedures for providing access to patient records by employees and authorized agents of a designated protection and advocacy system as required under state and federal law | 11/16/2012 |
| Discharge Summary | #HI-04 | Guidelines for completion of Discharge Summaries | 07/13/2009 |
| Documentation in Progress Notes | #HI-05 | Progress Note entries | 01/26/2011 |
| 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 | 11/02/2009 |
| 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. | 10/26/2009 |
| Guidelines for Release of Information | #HI-06 | Procedures for releasing information from medical records | 11/02/2009 |
| HIPPA Documentation and Record Retention | #HI-18 | Addresses documentation and record retention requirements
of the Health Insurance Portability and Accountability Act of 1996. |
11/02/2009 |
| Medical Records: Access and Security | #HI-07 | Procedures to control access to medical records and maintain security | 11/02/2009 |
| Medical Records: Facsimile Transmission | #HI-08 | Procedures governing sending and receiving medical records information via facsimile (fax) machine | 09/02/2009 |
| Mental Disabilities Board of Visitors -- Access to Patient Records | #HI-09 | Access to patient records by Board of Visitors staff | 11/16/2012 |
| 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." | 10/26/2009 |
| 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 | 11/09/2009 |
| 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 | 10/26/2009 |
Section X -- Housekeeping/Laundry |
|||
| Housekeeping Chemicals and Their Safe Use | #HL-01 | Procedures for use of chemical cleaning compounds | 04/30/2013 |
| Terminal Isolation Room Cleaning | #HL-02 | Cleaning of isolation rooms | 03/13/2012 |
Section XI -- Human Resources |
|||
| Access Control Keys | #HR-01 | Ensures appropriate access to all hospital areas | 10/19/2009 |
| Assignment of Utilization of Personnel | #HR-02 | Prohibits assignment of personnel based on gender | 10/19/2009 |
| Attendance & Work Hours | #HR-18 | Delineates length of work hours and break periods | 04/10/2012 |
| 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 | 10/19/2009 |
| Code of Ethics for Employees of Montana State Hospital | #HR-05 | Employee ethics policy | 10/26/2009 |
| 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. | 10/19/2009 |
| Dress Code Standards | #HR-07 | Employee dress code | 09/16/2011 |
| 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 | 10/19/2009 |
| Employee Conduct | #HR-06 | Rules of conduct for employees | 07/13/2009 |
| Employee Recreation | #HR-09 | Establishes rules for employee use of the hospital's recreation facilities | 12/23/2009 |
| Housing Policy | #HR-10 | Policy regarding the management of employee housing units | 10/19/2009 |
| Leave Policy | #HR-03 | Use of different types of Leave (eg sick leave, annual leave) | 10/26/2009 |
| On-Call Positions | #HR-11 | Establishes on-call staffing pool | 10/19/2009 |
| Performance Planning and Evaluation | #HR-12 | Employee performance planning and evaluations | 3/16/2011 |
| Personal cell phone use by employees | #HR-24 | To provide guidelines for use of personal cell phones by employees in the workplace. |
03/2/2011 |
| 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. | 10/19/2009 |
| Probation/Trial Period | #HR-14 | Designates probationary periods for employment | 10/19/2009 |
| Reimbursement for Damaged Employee Owned Property | #HR-13 | Limits MSH liability for loss or theft of personally owned articles | 02/03/2011 |
| Sexual Harassment | #HR-15 | Procedures for handling allegations of sexual harassment | 10/19/2009 |
| Sick Leave Abuse | #HR-16 | Defines abuse of sick leave and disciplinary procedures | 11/09/2009 |
| Verification of Licensure/Certification | #HR-17 | Procedures to ensure verification of licensure and certification for appropriate hospital employees | 10/19/2009 |
| Volunteers | #HR-19 | Establishes procedures for volunteers working at MSH | 10/26/2009 |
| Workplace Violence and Harassment Prohibited | #HR-21 | Procedures and guidelines adderssing occurrences of workplace violence and harassment | 10/19/2009 |
Page last updated: 05/01/2013
