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Policy Manual

Montana Mental Health
Nursing Care Center

Policy Manual

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Section

Title/Content

Date Issued or Revised

    Table of Contents 05/12/12
     
100  Administration   
  101 Mission Statement 04/28/16
  102 Organizational Chart 04/22/16 
       
  103 Policy Procedure 04/28/16
  104 Communication with News Media 04/28/16
  105 Superintendent Absence 04/28/16
  106 Ethics Committee 04/28/16
  107 Solicitation 04/28/16
  110 Pet Protocol 05/22/17
  110 Attachment 1 Pet Registration Form 05/22/17
  111 Elopement Risk 04/28/16
  112 Missing Persons 04/28/16
  112 Attachment 1 Instructions For Conduction A Search For A Missing Persons 04/28/16
  112 Attachment 2 Search Map 10/10/13
  113 Response to Violent Crime or Suicide 04/28/16
  118 Resident / Employee Transactions 04/28/16
  118 Attachment 1 Resident  /Employee Transaction Form 10/10/13
  119 Sexual Harassment 04/28/16
  119 Attachment 1 Equal Employment Opportunity, Non-Discrimination and Harassment Prevention 04/28/16
  120 Emergency Plan 04/28/16
  120 Attachment 1 Emergency Telephone Numbers 10/10/13
  120 Attachment 1a Emergency Telephone Numbers 10/10/13
  120 Attachment 2 General Orientation to Organization 10/10/13
  120 Attachment 3 Facility Map 10/10/13
  120 Attachment 4 Water Service 10/10/13
  120 Attachment 5 Strike Contingency Plan 10/10/13
  121 Safety Committee 04/28/16
  122 Tobacco Free Campus 04/28/16
  137 Visitors to the Facility 04/28/16
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200 Fiscal Property  
  201 Donated Funds 04/28/16
  202 Supply Order From (All Departments except Food Service 04/28/16
  202 Attachment 1 Supply Order From 10/10/13
  203 Purchasing Procedures 04/28/16
  203 Attachment 1 Requisition 04/14/11
  204 Disposition of State Property 04/28/16
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300 Business Office  
  302 Resident Checking / Bank Statement Reconciliation 10/19/16
  303 Contingent Revolving Account / Bank Statement Reconciliation 10/19/16
  304 Stale Dated Checks 10/19/16
  305 Resident Accounts Cash Box 10/19/16
  305 Attachment 1 Daily Cash Box Reconciliation 10/19/16
  305 Attachment 2 Monthly Cash Box Reconciliation 10/19/16
  306 Resident Trust Funds Month End Balance Report 10/19/16
  307 Signatures on Accounts Payable Vouchers 10/19/16
  307 Attachment 1 Accounts Payable Voucher 10/19/16
  308 Resident Estates 10/19/16
  309 Receipt & Deposit of Resident Account Checks 10/19/16
  310 Resident Account Purchases 10/19/16
  310 Attachment 1 Resident Account Voucher 10/19/16
  311 Resident Mail Orders 10/19/16
  312 Resident Funds Deposits & Withdrawals 10/19/16
  312 Attachment 1 Resident Accounts Withdrawal Certificate 10/19/16
  314 Resident Funds Held in Trust 10/19/16
  315 Copy Machine 10/19/16
  316 Resident Hair Care Services 10/19/16
  316 Attachment 1 Resident Hair Care Voucher 10/19/16
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400 Personnel  
  401 Sick Leave Policy - Department of Administration 10/19/16
  401 Attachment 1 Sick Leave Policy - Montana Mental Health Nursing Care Center 10/19/16
  401 Attachment 2 Request For Leave of Absence 10/19/16
  402 Sick Leave usage for Intermittent Employees 10/19/16
  403 Annual Vacation Leave Usage 10/19/16
  403 Attachment 1 Annual Vacation Leave Usage - Department of Administration 10/19/16
  404 Use of Earned Holiday Time 10/19/16
  404 Attachment 1 Request For Leave of Absence 10/19/16
  404 Attachment 2 Holidays 10/19/16
  405 Employee Request Form 10/19/16
  405 Attachment 1 Request For Leave of Absence 10/19/16
  406 Cancelation of Scheduled Annual Leave, Holiday Leave & Leave without Pay 10/19/16
  407 Inservice 10/19/16
  408 Leave of Absence without Pay 10/19/16
  408 Attachment 1 Human Resource Leave w/o Pay Policy 10/19/16
  409 Tardy or Absent from Work 10/19/16
  410 Hiring of Employees 10/19/16
  410 Attachment 1

Recruitment and Selection Policy

10/19/16
  410 Attachment 2 Sample Scoring Sheet 10/19/16
  410 Attachment 3 Human Resource Policy #115  
  411 Letters of Hire and Denial 10/19/16
  412 Affirmative Action / Equal Employment Opportunity Policy 10/19/16
  412 Attachment 2 Equal Opportunity 10/19/16
  413 Work Related Injury 10/19/16
  413 Attachment 1 Telephone Reporting Worksheet 10/19/16
  413 Attachment 2 Incident Report Check List 10/19/16
  414 Employee Dress and Grooming 04/21/17
  415 Employee Evaluations 10/19/16
  415 Attachment 1 Performance Management and Evaluation 10/19/16
  415 Attachment 2 Employee Performance Evaluation 10/19/16
  416 Employee’s Personnel File Information 10/19/16
  417 Use of Alcohol Beverages and non-Prescribed Conscious Altering Drugs 10/19/16
  417 Attachment 1 Human Resource Policy #160 10/19/16
  417 Attachment 2 Drug Free Work Place/Substance Abuse Policy 10/19/16
  418 Time Clock Usage 10/19/16
  419 Investigations 10/19/16
  419 Attachment 1 Human Resource Guide #220 10/19/16
  420 Rest Break Areas 10/19/16
  420 Attachment 1 Indoor / Outdoor Break Areas Map 10/19/16
  421 Employee Conduct 10/19/16
  421 Attachment 1 Guidelines for Employee Conduct 10/19/16
  422 New Employee Orientation 10/19/16
  422 Attachment 1 New Employee Orientation Checklist 10/19/16
  423 Worker’s Compensation 10/19/16
  423 Attachment 1 Human Resource Policy #340 10/19/16
  424 Employee Communication 10/19/16
  427 Employee Sick Leave Call-In 10/19/16
  428 Leave Requests 10/19/16
  428 - Attachment 1 Request For Leave of Absence 10/19/16
  429 Non Union Grievance 10/19/16
  429 Attachment 1 Grievance Policy - Administrative Rules of the State of Montana (ARM) 10/19/16
  430 Employee Telephone Usage 10/19/16
  431 Thanksgiving, Christmas and New Year’s Holiday Scheduling 10/19/16
  432 Employee Mail 10/19/16
  432 Attachment 1 Procedures For Handling Suspicious Envelopes Or Packages 10/19/16
  433 Employee Montana Operator’s Drivers License 10/19/16
  434 Employee Identification Tags 05/22/17
  435 Employee Rest Breaks & Meal Periods 10/19/16
  435 Attachment 1 Breast Feeding Policy 10/19/16
  436 Early Return to Work 10/19/16
  436 Att Early Retn to Work Att Early Return to Work 10/19/16
  436 Attachment 1 Return to Work Recommendations 10/19/16
  436 Attachment 2 ERTW Letter from Employer to Injured Employee 10/19/16
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500 Nursing  
  501 Fall Risk Policy 05/22/17
  501 Attachment 1 Fall Risk Assessment 05/22/17
  502 Resident Accident Incident Reporting 05/22/17
  502 Attachment 1 Accident or Incident Report 05/22/17
  503 Short Wave Radios 05/22/17
  504 Registered Nurses Licenses 05/22/17
  505 Central Venous Catheter Care 05/22/17
  506 MANDT Hold &/or Involuntary Administration of IM Medication 05/22/17
  506 Attachment 1 MANDT Hold &/or Involuntary Administration of IM Medication Form 05/22/17
  507 Medication Error Report Prevent 05/22/17
  507 Attachment 1 Med Error Report Form 05/22/17
  507 Attachment 2 Medication Administration Skills Review 05/22/17
  508 Medication Aide II 05/22/17
  508 Attachment 1 Medication Aide II Curriculum 05/22/17
  509 Pain 5/22/17
  509 Attachment 1 Pain Assessment 05/22/17
  509 Attachment 2 Pain Flow 5/22/17
  510 Certified Nursing Assistants Assigned Work Areas 05/22/17
  513 Use of Grand Master Key 05/22/17
  515 Continuing Education 05/22/17
  517 Safe Medical Devices Act 05/22/17
  519 Secure Wing / E Wing 05/22/17
  520 Admitting Residents to Secure Unit / F-Wing / Firefly Way 05/22/17
  522 Admissions Criteria to E Wing 05/22/17
  523 Assistive Restraints – Safety Device or Restraint 05/22/17
  523 Attachment 1 Restraint Authorization 05/22/17
  523 Attachment 2 Family/Guardian 05/22/17
  523 Attachment 3 Restraint Identification 05/22/17
  524 Resident Transportation 05/22/17
  524 Attachment 1 Travel Log 05/22/17
  525 Admissions Procedure 05/22/17
  525 Attachment 1 Inventory of Personal Effects on Admission/Discharge 05/22/17
  525 Attachment 2 Initial Care Plan 05/22/17
  525 Attachment 3 Nursing Physical Assessment 05/22/17
  525 Attachment 5 Pain Assessment 05/22/17
  525 Attachment 6 Pain Flow Sheet 05/22/17
  528 Secure Care system 05/22/17
  528 Attachment 1 Check List for Secure Care Alarms 05/22/17
  529 Care Planning 05/22/17
  530 Resident Death 05/22/17
  530 Attachment 1 Contract Attorney 05/22/17
  530 Attachment 2 Inventory of Personal Effects on Admission/Discharge 05/22/17
  530 Attachment 3 Resident Death Report 05/22/17
  530 Attachment 4 Authorization for Removal of Deceased Resident 05/22/17
  530 Attachment 5 Funeral Plans Questionnaire 05/22/17
  530 Attachment 6 Vital Statistics for Funeral Homes 05/22/17
  530 Attachment 7 Post Mortem Care 5/22/17
  534 Involuntary Medications 05/22/17
  534 Attachment 1 Involuntary Medication Review Committee 05/22/17
  535 Electronic Signatures 05/22/17
  536 Abnormal Involuntary Movement Scale Examination 05/22/17
  536 Attachment 1 AIMS 05/22/17
  541 Neuro Assessment 05/22/17
  541 Attachment 1 Vital Statistics 05/22/17
  542 Oxygen Therapy 05/22/17
  546 Pressure Ulcers: Prediction and Prevention 05/22/17
  546 Attachment 1 Braden Scale 05/22/17
  547 Anti psychotic Rx use and monitoring

05/22/17

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600 Infection Control  
  601 Cleaning & Decontaminating Body Fluid Spills 03/01/16 
  602 Control of Communicable & Infectious Diseases 03/01/16
  603 Infection Control Committee 03/01/16
  604 Tuberculin Detection, Prevention & Control Policy 03/01/16
  604 Attachment 1 Consent for PPD 03/01/16 
  604 Attachment 2 Certification from Active Tuberculosis 03/01/16
  604 Attachment 3 TB Screening Questionnaire 03/01/16
  608 Management of Infected Health Care Workers 03/01/16 
  612 Residents with Tuberculosis 03/01/16 
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700 Food Service  
  701 Meal Serving Plan 04/17/15
  702 Scope of the Food Service Department 10/09/14
  703 Dietary Department Interdepartmental Communications and Relations 04/17/15
  704 New Admissions and Diet Changes 10/09/14
  704 Attachment 1 Liberalized Diet Plan 10/09/14
  705 Change of Residents Seating Location 10/09/14
  706 Diet Manual 04/17/15
  707 Nourishments 10/09/14
  708 Employee Meal Service 10/09/14
  709 Visitor’s Meals 10/09/14
  710 Hair Restraints 10/09/14
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800 Maintenance  
  801 Energy Conservation 04/17/15
  802 Fire Protection System, Equipment & Training Employees 04/17/15
  803 Maintenance Work Request Form 04/17/15
  803 Attachment 1 Maintenance Department Work Request  
  804 Emergency Shut-0ffs for Main Gas Line, Main Electrical Power, Main Water Supply, Main Fire Sprinkling System 04/17/15
  805 Traffic Control 04/17/15
  806 State Vehicles 04/17/15
  806 Attachment 1 Parking Map  
  807 Boiler Observation Check 04/28/16
  808 After Hours Emergency Numbers 04/28/16
  809 Key Policy 04/17/15
  811 Relocation and Installing of Appliances & Equipment 04/17/15
  812 Fire Watch 04/17/15
  813 Fire Plan Policy 03/01/16
  813 Attachment 1 Fire Report Form  
  813 Attachment 2 Fire Drill Report 04/17/15
  813 Attachment 3 Information About The Fire Alarm System  
  814 Environmental / Safety Inspection Team 09/22/16
  814 Attachment 1 Environmental Safety Inspection 09/22/16
  815 Employee Vehicle Policy 04/17/15
  815 Attachment 1 Employee Parking 04/17/15
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900 Laundry  
  901 Laundry Services 07/09/15 
 Top
 
1000 Housekeeping  
  1001 Sanitation 07/09/15 
       
  1003 Pest Control 08/12/16 
 Top
 
s1100 Clinical Support  
  1101 Scope of Social Services  07/09/15
  1102 Resident Social History Evaluation/Progress Notes  7/09/15
  1102 Attachment 1 Social History/Assessment  
  1102 Attachment 2 Social Service Assessment  
  1103 Resident’s Rights 07/09/15
  1103 Attachment 1 Page 1 Resident’s Rights and Responsibilities  
  1103 Attachment 1 Page 2 Resident’s Rights and Responsibilities  
  1103 Attachment 2 Family Information Form Attachment  
  1104 Abuse, Exploitation, Mistreatment and / or Neglect of Residents 07/09/15
  1104 Attachment 1 Reporting Form 24 Hour Report  
  1105 Resident Rights Grievance Procedure  
  1105 Attachment 1 Resident Rights Grievance Report Form  
  1106 Residents Lost or Stolen Items Procedure 07/09/15
  1107 Resident Mail 07/09/15
  1107 Attachment 1 Personal Finance Permission  
  1107 Attachment 2 Representative Payee Procedure - Financial Statement  
  1108 Residents Use of the Telephone 10/04/16
  1109 Photographs 07/09/15
  1109 Attachment 1 Release for Photograph  
  1110 Pet Protocol 07/09/15
  1112 Resident Off-Campus Release 07/09/15
  1112 Attachment 1 Off-Campus Release Agreement  
  1113 Resident Sharp Object Possession 07/09/15
  1114 Resident Referral Process 07/09/15
  1114 Attachment 1 Information Admission by Involuntary Commitment  
  1114 Attachment 1a Application for Admission by Involuntary Commitment  
  1114 Attachment 2 Information Voluntary Admission  
  1114 Attachment 2a Application for Voluntary Admission  
  1115 Advance Medical Directive 07/09/15
  1115 Attachment 1 Instructions for Healthcare (Living Will)  
  1116 Facility Initiated Discharge Protocol 07/09/15
  1116 Attachment 1 Care Plan Team  
  1116 Attachment 2 Notice Of Transfer or Discharge  
  1116 Attachment 3 Resident Letter  
  1116 Attachment 4 Aftercare Plan  
  1116 Attachment 5 Discharge Letter  
  1116 Attachment 6 Information for Business Office on Resident Transfers  
  1117 Donation Receipt 07/09/15
  1118 Resident Admissions & Orientation 07/09/15
  1118 Attachment 1 Funeral Plans Questionnaire  
  1118 Attachment 2 Family information  
  1118 Attachment 3 MDS Letter  
  1118 Attachment 4 Abuse Education Letter  
  1118 Attachment 5 Consent Routine Proc  
  1118 Attachment 6 Consent Authorization Letter  
  1118 Attachment 7 Authorization to Consent to Treatment of Incompetent Patient  
  1118 Attachment 7a Authorization to Consent to Treatment  
  1118 Attachment 8 HIPAA Information  
  1118 Attachment 9 Privacy Form  
  1118 Attachment 10 Authorization to Share Protected Health Information  
  1118 Attachment 10a Authorization to Share Protected Health Information  
  1119 Resident Guardianships 07/09/15
  1119 Attachment 1 Guardianship Recommendation  
  1120 Bed Hold Policy 07/09/15
  1120 Attachment 1 Bed Hold Policy  
  1120 Attachment 2 Bed Hold Payments  
  1121 Notice of Resident Discharge or Transfer 07/09/15
  1122 Discharge Planning 07/09/15 
  1122 Attachment 1 Discharge Planning Care Plan Team  
  1122 Attachment 2 Notice of Transfer or Discharge  
  1122 Attachment 3 Aftercare Plan  
  1122 Attachment 4 Aftercare Plan Letter  
  1122 Attachment 5 Request for Discharge Against Medical Advice  
  1122 Attachment 6 Information for Business Office on Resident Transfers  
  1124 Accommodating Patients’ Special Education Needs 07/09/15
  1125 Resident Work Plan 07/09/15 
  1126 Resident Work Program/Performance Evaluations 07/09/15
  1126 Attachment 1 Performance Evaluation  
  1126 Attachment 2 Resident Assessment for Determination for Rate of Pay  
  1126 Attachment 3 Determination for Rate of Pay  
  1127 Resident Work Program Payroll 07/09/15
  1127 Attachment 1 Employee Time and Attendance Report  
  1128 Recruitment/Selection of Resident Workers 07/09/15
  1128 Attachment 1 Resident Work Program Payroll Notification Form  
  1129 Resident Work Program Dismissal 07/09/15
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1200 Recreation  
  1201 Mission and Purposes of the Department 10/08/15
  1202 Resident Recreational Outings 10/08/15
  1202 Attachment 1 Resident Recreation Event 04/11/13
  1203 Faith and Cultural Services 10/08/15
  1204 Volunteer Services 10/08/15
  1205 Recreation Program Documentation 10/08/15
  1205 Attachment 1 Recreation Assessment 04/11/13
  1205 Attachment 2 Recreation Participation Record 04/11/13
  1205 Attachment 3 Recreation Observation 04/11/13
  1206 Activities Program 10/08/15
  1207 Protective Wing Psychosocial Needs 10/08/15
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1400 Medical Records  
  1401 Medical Records Admission 10/08/15
  1401 Attachment 1 Immunization & PPD Schedule  
  1402 Discharge Planning 10/08/15
  1402 Attachment 1 Resident Letter  
  1402 Attachment 2 Notice Of Transfer Or Discharge  
  1402 Attachment 3 Aftercare Plan  
  1402 Attachment 4 Resident Letter  
  1402 Attachment 5 Request for Discharge Against Medical Advice  
  1402 Attachment 6 Information for Business Office on Resident Transfers  
  1403 Arrangement of Medical Record Chart at the Nursing Stations 10/08/15
  1407 Confidentiality of Resident Information 10/08/15
  1407 Attachment 1 Authorization for Release of Information 10/08/15
  1408 HIPAA Privacy Policy 10/08/15
  1408 Attachment 1 Support Services  
  1409 Daily Census Report 10/08/15
  1409 Attachment 1 Daily Census Report  
  1416 Monthly Census Statistical Report 10/08/15
  1416 Attachment 1 Monthly Report  
  1416 Attachment 1a Annual Report  
  1416 Attachment 1b Report  
  1417 Patients Daily Census 10/08/15
  1417 Attachment 1 Patients Daily Census Form  
  1419 Verbal Orders from Physician 10/08/15
  1419 Attachment 1 Physician's Telephone Orders  
  1420 Admission and Discharge Register 10/08/15
  1422 Auditing and Purging of Medical Records 10/08/15
  1423 Resident Record Retention / Retrieval 10/08/15
  1424 Social Media and Networking 10/08/15
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1500 Exposure Control Plan  
  1500 Universal Precautions / Standard Precautions 03/01/16 
  1501 Safety Devices 03/01/16
  1502 Hand Hygiene 03/01/16
  1503 Handling and Disposal of Needles and Sharps 03/01/16
  1504 Ingestion of Blood Borne Pathogens 03/01/16
  1505 Handling of Potentially Infections Specimens 03/01/16
  1506 Personal Protective Equipment (PPE) 03/01/16 
  1507 Cleaning Potentially Contaminated Equipment & Work Areas 03/01/16
  1508 Infections / Biohazard Waste 03/01/16
  1509 Laundry Handling Practices 03/01/16
  1510 Blood Borne Diseases and Health Care Workers 03/01/16
  1511 Hepatitis B Vaccination 03/01/16
  1511 Attachment 1 Consent Form 03/01/16 
  1511 Attachment 2 Declination Form 03/01/16
  1511 Attachment 3 Revaccination Notice 03/01/16
  1512 Exposure Incident Evaluation and Follow-Up 03/01/16
  1512 Attachment 1 Exposure Incident Report 03/01/16 
  1512 Attachment 2 Post Exposure Evaluator Written Opinion 03/01/16
  1512 Attachment 3 Employee Exposure to Blood and Body Fluids

 

  1513 Labeling of Potentially Hazardous Material
  1515 Occupational Exposure Training 03/01/16 
  1516 Employee Medical Records 03/01/16
  1516 Attachment 1 Employee Medical Record 03/01/16
  1516 Attachment 2 Post-Exposure Follow-Up 03/01/16
  1516 Attachment 3 Post-Exposure Follow-Up 03/01/16
  1516 Attachment 4 Post-Exposure Follow-Up Potentially Infectious Material 03/01/16
  1516 Attachment 5 Hepatitis B & Hepatitis C Blood Test Consent 03/01/16
  1516 Attachment 5a Hepatitis B Virus And Hepatitis C Virus Blood Test 03/01/16
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1600 Pharmacy  
  1600 Access to Pharmacy 03/01/16
  1601 Handling of Hazardous / Chemotherapeutic Drugs 03/01/16
  1602 Dealing with Licensing Agencies 03/01/16
  1603 Unit Dose Drug Distribution System 03/01/16
  1604 Security of Pharmacy Premises 03/01/16
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