Montana State Hospital
Policy Manual -- Volume II
Table of Contents
May 1, 2013
Policy # |
Description |
Last Issue |
|
|---|---|---|---|
Section XII -- Infection Control |
|||
| Cleaning of Non-Critical, Reusable Patient Care Equipment | #IC- 19 | PURPOSE: To establish a process for the cleaning of non-critical, reusable patient care equipment. | 03/01/2010 |
| Body Piercing and Tattooing Prohibited | #IC-17 | To prevent risk of infection or other physical or emotional harm to patients from body piercing or tattooing during hospitalization. | 08/18/2011 |
| Employee Health Record & Immunization/Testing Requirements | #IC-02 | To provide current record of all employees' immunization and tuberculosis screening status and explain immunization and testing requirements of emlployees | 02/03/2011 |
| Exposure Control Plan | #IC-03 | Establishes responsibilities to minimize risk of acquiring bloodborne disease due to occupational exposure | 05/18/2010 |
| Guidelines for Isolation Precautions | #IC-11 | Isolation techniques to prevent the spread of disease | 08/11/210 |
| Handling
Needles and Sharps |
#IC-04 | Procedures for disposal of needles and sharps | 07/21/2011 |
| Handwashing | #IC-05 | Handwashing procedures | 12/18/2009 |
| Hepatitis B Vaccination Program | #IC-06 | Provision of Hepatitis B vaccines to employees | 11/19/2012 |
| Infection Control - Care of Contaminated Articles of Clothing and Linen | #IC-07 | Procedures for handling contaminated articles of clothing and linen | 05/18/2010 |
| Infection Control Plan | #IC-09 | Describes MSH Infection Control Program | 02/17/2012 |
| Infection Report | #IC-10 | Establishes system for keeping records on patient infections | 10/1/2009 |
| Management of an Employee with an Occupational Exposure to a Bloodborne Pathogen | #IC-12 | Procedures to be taken in the event of an accidental exposure to bloodborne pathogens | 12/20/2010 |
| Pediculosis/Scabies | #IC-18 | To promptly diagnose and treat a patient that presents with pediculosis and scabies. | 03/01/2010 |
| Nosocomial Infections | #IC-13 | Classification, care, and review procedures of nosocomial infections | 11/25/2009 |
| Personal Protective Equipment | #IC-14 | Procedures to assure the availability of personal protective equipment and training in proper use | 09/14/2009 |
| Standard Precautions | #IC-15 | Describes procedures for prevention of exposure to bloodborne pathogens | 12/18/2009 |
| Tuberculosis Surveillance for Patients of Montana State Hospital | #IC-16 | Guidelines for TB screening of MSH patients | 07/21/2011 |
Section XIII -- Medical Staff |
|||
| Credentialing and Privileging | #MS-01 | Defines procedures for credentialing and privileging of physicians and dentists | 08/01/2012 |
| Medication Order Standards | #MS-03 | Establishes standards for Licensed Independent Practitioners (LIPs) to write medication orders on Physician’s Order Forms to ensure compliance with standards and reduce errors | 03/02/2010 |
| Physician On-Call Coverage | #MS-02 | Provision of on-call physician/psychiatrist coverage | 08/11/2010 |
| Employee Healthcare Services | #MS-04 | To specify circumstances under which Montana State Hospital Medical Staff may provide healthcare services to other Hospital employees. | 08/17/2011 |
Section XIV -- Nursing Services |
|||
| Medication Administration and Safe Handling, Principles of | #NS-02 | Administration and handling of medications | 05/12/2011 |
| Nursing Assessment and Diagnosis | #NS-03 | Nursing Assessment procedures | 02/03/2011 |
| Pharmacy Night Locker | #NS-05 | Addresses access to medications at night | 11/01/2011 |
Section XV -- Patient Rights |
|||
| Informed Consent for Treatment | #PR-02 | Procedures for obtaining a patient's informed consent
for treatment |
08/01/2012 |
| Patient Grievance Procedure | #PR-03 | Describes the Patient Grievance Process | 11/30/2009 |
| Patient Rights and Grievance Procedure Information | #PR-04 | Procedure for presenting information to patients on their Rights and Grievance Procedure | 07/01/2011 |
| Voting Rights of Patients | #PR-05 | Procedures for providing assistance to patients wishing to exercise their right to vote | 05/18/2010 |
| Medical Marijuana Possession | #PR-13 | To describe procedures for handling medical marijuana legally in the possession of patients at the time of admission. | 05/17/2012 |
Section XVI -- Physical Health |
|||
| Adverse Drug Reaction Reporting | #PH-10 | Procedures for reporting adverse drug reactions |
08/01/2012 |
| Death and Autopsy | #PH-01 | Procedures to be followed upon the death of a patient | 02/11/2011 |
| Dietary
Supplement |
#PH-02 | Prohibits use of herbal supplements | 07/01/2009 |
| Informing/Communicating
Changes in Patient's Condition |
#PH-03 | Responsibility for providing information about changes in physical health to family members | 08/01/2012 |
| Medical
Clinic Services |
#PH-04 | Operation of the Medical Clinic | 09/14/2009 |
| Medical Emergency Response -- Initiating a "Code Blue" | #PH-11 | To provide a plan for response to medical emergencies | 10/26/2009 |
| Medical Marijuana | #PH-13 | To describe procedures for handling medical marijuana legally in the poossession of persons-served at the time of admission. | 02/24/2009 |
| Metabolic Syndrome Policy | #PH-12 | To educate patients on the risk factors that lead to Metabolic Syndrome and to screen selected patients for Metabolic Syndrome. | 03/01/2010 |
| Organ
and Tissue Donation |
#PH-05 | MSH will not routinely attempt to identify potential organ and tissue donors | 01/20/2012 |
| Physical
Health Assessment |
#PH-06 | Provision of physical exams | 07/13/2009 |
| Procedure
for Obtaining Informed Consent for Medical and Surgical Procedures |
#PH-07 | Addresses informed consent for surgical procedures | 09/14/2009 |
| Respiratory
Therapy Services |
#PH-08 | Provision of Respiratory Therapy Services | 09/14/2009 |
| Surgical Procedures, Use of Anesthesia and Blood Products at Montana State Hospital | #PH-09 | Describes limited surgical procedures provided at MSH | 09/14/2009 |
Section XVII -- Psychology Services |
|||
| Psychological Assessment and Evaluation | #PGS-01 | Describes psychological assessment and evaluation services at MSH | 02/23/2011 |
Section XVIII -- Psychiatric Services |
|||
| Clozaril
and Seroquel Standard Titration Schedules |
#PS-01 | Protocol for prescribing Clozaril | 09/21/2012 |
| Involuntary
Medications |
#PS-02 | Procedures for involuntary medication administration as allowed under Montana Statute | 07/01/2009 |
| Practitioner
Review of Patient Medication Regimen |
#PS-03 | Procedures for meeting requirements of 53-21-145 which require weekly review of medication | 08/01/2012 |
| Psychiatric
Assessments |
#PS-04 | Psychiatric assessment procedures | 10/26/2009 |
| Standing
Order: Drug Guidelines for Lab |
#PS-05 | Standardized lab tests for patients taking anticonvulsant and antipsychotic drugs | 07/01/2009 |
Section XIX -- Quality Improvement |
|||
| Death Review | #QI-01 | Procedures for reviewing patient deaths to evaluate quality of care | 06/07/2012 |
| Quality
Improvement Plan |
#QI-02 | Development of annual Quality Improvement Plan | 05/18/2010 |
| Seclusion and Restraint Committee | #QI-04 | To provide a post-incident review process for all restraint and seclusion interventions. |
02/11/2011 |
| Serious Adverse Events/Significant Event Review |
#QI-05 | Guidelines for conducting a risk-prevention analysis in response to significant or sentinel events | 08/11/2010 |
Section XX -- Rehabilitation Therapy Services |
|||
| Rehabilitation
Assessment |
#RTS-03 | Completion of Rehabilitation Therapy Assessments and Care Plans | 12/06/2010 |
| Substance Use Disorder Assesment and Referral | #RTS-02 | To provide guidelines for the Substance Use Disorder screening, assessment and referral processes. | 05/18/2010 |
| Vocational Assessment | #RTS-05 | To provide procedural guidelines governing the administration of the Vocational Assessment and its integration into the Master Treatment Plan of Montana State Hospital patients. To ensure that appropriate therapeutic vocational services are provided in a timely manner. | 05/19/2010 |
| Occupational Therapy Services | #RTS-06 | To provide procedural guidelines governing the administration of Occupational Therapy Services and its integration into the Master Treatment Plan of Montana State Hospital patients. To ensure that appropriate therapeutic occupational therapy services are provided in a timely manner. | 08/24/2012 |
Section XXI -- Safety |
|||
| Contraband
and Searches |
#SF-02 | Defines contraband and establishes search procedures | 05/12/2011 |
| Door Stop Usage | #SF-09 | Outlines the use of door stops in patient occupied areas of Montana State Hospital. | 08/11/2010 |
| Safety Committee |
#SF-03 | To address all areas of hospital operation in an attempt to ensure and improve safety for all patients, staff, and visitors. | 07/11/2011 |
| Hazardous Condition
Reporting Policy |
#SF-06 | Outlines procedures for reporting and responding to possible hazardous conditions affecting the overall safety of patients, employees and visitors of MSH. | 03/01/2010 |
| Incident
Response and Reporting |
#SF-04 | Describes response procedures for different types of incidents and completion of the Incident Report Form | 12/09/2011 |
| Mandatory Lockout Procedures/Hazardous Energy Control | #SF-08 | Establishes Montana State Hospital’s minimum requirements for the isolation of hazardous energy, complying with OSHA 29 CFR 1910.147 | 10/16/2012 |
| Medical Device Reporting | #SF-05 | Procedures for meeting FDA requirements for reporting problems with medical devices | 03/15/2010 |
| Workman's Compensation | #SF-07 | Identifies responsibilities in the event of a work-related injury that results in Worker's Compensation benefits. | 12/09/2011 |
Section XXII -- Social Services |
|||
| Social Assessment, (Initial, Interim, Annual, and Forensic) | #SS-01 | Completion of Social Work Assessments | 12/06/2010 |
| Special Education Services | #SS-02 | To ensure that patients between the ages of 18 and 22 served at MSH have been assessed for Special Education Services and provided these services. | 08/01/2011 |
Section XXIII -- Staff Development |
|||
| Tour Requests & Procedures | #SD-01 | Procedures for conducting tours of MSH for educational groups, the media, etc. | 07/01/2011 |
Section XXIV -- Support Services |
|||
| Preventative Maintenance Program | #SPS-01 | Describes preventative maintenance program | 06/01/2010 |
Section XXV -- Treatment |
|||
| Abnormal Involuntary Movement Scale (AIMS) Examination for Tardive Dyskinesia | #TX-01 | AIMS assessment procedures | 09/21/2012 |
| Advance Directives (Declarations) | #TX-02 | Advance Directives | 07/13/2009 |
| Allegations of Abuse or Neglect | #TX-17 | Procedures to be taken when allegations of patient abuse occur | 03/16/2011 |
| Animal Visitation | #TX-21 | Guidelines allowing patients to have personal visits from people bringing pets and for the use of animals as part of treatment and rehabilitation programs provided by MSH. | 03/15/2010 |
| Treatment and Leisure Pass | #TX-04 | To provide guidelines for patients attending on campus treatment and leisure activities. | 07/01/2011 |
| Consultation Services | #TX-05 | Procedures for obtaining consultations from other professionals at MSH or in the community | 11/01/2011 |
| Crisis Intervention Team | #TX-18 | Provides guidelines for utilizing a team approach to crisis intervention | 05/27/2009 |
| Escorting Patients Off Grounds | #TX-27 | Provides for safety and security when escorting patients off grounds | 09/21/2011 |
| Friendly, Welcoming, and Professional Attitude | #TX-30 | To provide direction to employees regarding attitudes and feelings towards patients and their families and friends | 11/19/2012 |
| Event Review | #TX-25 | Provides for a process to review every event leading to the use of seclusion or restraints and to review other significant events that result in serious physical aggression toward other patients and staff | 05/10/2012 |
| Guardianship | #TX-07 | Procedures for guardianship | 01/20/2012 |
| Institutional Review Board | #TX-24 | Establishes an Institutional Review Board (IRB) to review and approve research activities at MSH involving or affecting hospital patients | 07/13/2007 |
| Interpreter Services | #TX-20 | Guidelines for intrepreter services for non-English or limited English speaking patients, or for a patient with a hearing impairment | 07/13/2009 |
| Intra-Campus Transfers | #TX-08 | Transfer of patients between treatment programs | 08/01/2012 |
| #TX-26 | To ensure appropriate review and oversight of non-standard treatment interventions proposed by clinical staff at Montana State Hospital. |
02/20/2012 | |
| Pastoral Services | #TX-09 | Meeting spiritual and religious needs of patients | 10/08/2009 |
| Patient Assessment | #TX-10 | General policy regarding patient assessment procedures | 08/01/2012 |
| Patient Gift Giving | #TX-28 | General policy to address issues related to buying, selling, trading, or gift giving | 06/01/2010 |
| Patient Sexual Behavior | #TX-11 | Patient sexual behavior | 04/29/2010 |
| Patient Treatment Plan | #TX-12 | Procedure for development and implementation of patient treatment plans | 02/29/2012 |
| Patients' Allocated Monthly Spending Allowance | #TX-19 | To provide guidelines for patients regarding utilization of their financial resources | 09/01/2007 |
| Suicide Precautions | #TX-14 | Suicide precautions | 11/19/2012 |
| Use of Restraints for Non-Violent Non-Self-Destructive Behaviors | #TX-31 | To provide guidelines for the appropriate use of restraints for the physical safety of patients with non violent or non self-destructive behaviors. | 04/30/2013 |
| Unauthorized Leave Precautions | #TX-23 | Standard procedures for use of unauthorized leave precautions. | 06/01/2010 |
| Use of Seclusion and Restraint | #TX-16 | Use of seclusion and restraint interventions | 09/16/2011 |
| Video Taping Policy | #TX-29 | To establish guidelines for video taping planned interventions | 11/14/2011 |
| Use of Protective Hood | #TX-32 | To define the accepted use of protective hoods when individuals display spitting / biting behaviors and to provide protection against infectious diseases or harm associated with a person who is spitting and/or biting. | 03/29/2012 |
Page last updated: 05/01/2013
