Department of Public Health & Human Services

Montana State Hospital
Policy Manual -- Volume I

Table of Contents
August 1, 2006

 

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. 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

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

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

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

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

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

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

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

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

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

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