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Policy Manual Volume 1

Montana State Hospital
Policy Manual -- Volume I

Table of Contents
  September 25, 2018


Policy #


Last Issue Date

Section I -- Admission and Discharge

Admission Policy #AD-01 Establishes criteria and procedures for admission to MSH 07/28/2015
Discharge or Conditional Release from Civil Commitment #AD-02 Clarifies standards, responsibilities, and procedures for the discharge or conditional release of patients under a civil involuntary or voluntary commitment to MSH for inpatient psychiatric treatment. 10/18/2016
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. 04/21/2016
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. 11/19/2015
Management of Patient's Personal Effects #AD-03 Provides instruction for management of personal items belonging to patients of Montana State Hospital 06-15-2017
Pre-Placement Visit #AD-06 To establish procedures between MSH and community providers for pre-placement visits and pre-placement visits with subsequent discharges. 04/13/2015
Temporary Leave to Court Custody #AD-07 To provide for temporary release of a patient for court proceedings. 05/06/2015

Section II -- Administration

Access to Patient & Treatment Areas by Designated Protection & Advocacy System #ADM-13 To assure that representatives of the protection and advocacy system designated by the State of Montana are provided reasonable unaccompanied access to MSH patients. 04/08/2016
Access to Patient & Treatment Areas by Mental Disabilities Board of Visitors Staff #ADM-14 To assure that representatives of the Mental Disabilities Board of Visitors are provided access to MSH patients to perform their duties.


Centralized Contracting #ADM-01 Procedures for managing contracted services 04/21/2016
Description of Services #ADM-05 Defines MSH's role in providing psychiatric services. 05/08/2014
Firearms Carried by Law Enforcement Officials #ADM-02 Prohibits law enforcement officers from carrying fire arms into patient occupied buildings. 07/10/2014
Governance #ADM-09 Identifies responsibilities for governance, management, and control of Montana State Hospital. 01/18/2017
Parking Policy #ADM-11 To outline procedures for employees, visitor, and handicapped parking on the Montana State Hospital campus 07/20/2017
Patient Visitation #ADM-08 Establishes procedures and hours for visiting patients. 09/05/2014
Pharmaceutical Industry Representatives #ADM-10 To establish guidelines for interactions between staff of Montana State Hospital and Pharmaceutical Industry Representatives. 03/31/2014
Policy Development, Revision, Format, Approval, and Distribution #ADM-04 Describes procedure for development, approval, and dissemination of hospital policy/procedure. 05/21/2015
Security Camera System


To provide guidance regarding the security camera system in Montana State Hospital and the maintenance and use of records generated by the system. 05/02/2014
Tobacco and Nicotine #ADM-07

To promote a safe and healthy environment on the Montana State Hospital Campus.


Section III -- Business Services

Disposition of State Property #BS-01 Procedures regarding the disposition on non-expendable state property. 04/21/2016
Employee Charges for Photocopies #BS-10 To ensure photocopy expenses incurred at MSH are paid. 05/11/2015
Front Desk Change Fund #BS-07 Establishes procedures for the front desk change fund for use in the sale of visitor meal tickets. 09/08/2016
Imprest Cash Account #BS-02 Procedures for the operation of the Imprest Cash Account (petty cash fund). 05/06/2015
Interagency Charges for Photocopies #BS-06 DPHHS agencies utilizing MSH copy machines will be charged an established and reasonable fee per copy. 05/11/2015
Operation of Patient Deposit for MSH #BS-03 Procedure for the operation of the Patient Deposit Office. 02/22/2016
Patient Travel #BS-04 Procedure for providing funds for bus or airline tickets for patients. 05/06/2015
Reimbursement for Damage Destruction of Hospital Property #BS-05 An organized procedure to provide reimbursement for the destruction or damage of hospital property. 04/21/2016
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. 04/21/2016
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. 04/21/2016

Section IV -- Commitment/Recommitment Petitions

Petitions for Commitment/Recommitment, and Receiving and Recording Hearings/Orders #CP-01 Procedure for filing commitment or recommitment petitions. 09/19/2018

Section V -- Dental Services

Anesthesia Use in Dental Procedures #DL-01 Procedures for administration of anesthesia for dental procedures. 09/14/2018
Dental Records #DL-02 Procedures for maintaining dental records. 09/14/2018
Dental Services #DL-03 Procedures for the provision of routing and emergency dental services for MSH patients. 09/14/2018

Section VI -- Dietary Services

Clinical Nutrition Services #DS-01 Procedures for ordering special diets and food supplements; describes dietary assessment procedures. 04/28/2016
Dietary Glove Use #DS-04 To protect food, to prevent cross-contamination by minimizing bare hand contact with cooked and ready-to-eat foods, and to protect patrons from contagious and foodborne illness. 02/24/2014
Food-Drug Interactions #DS-02 Procedure to inform patients of drug-food interactions which require dietary modifications. 09/22/2017
Provision of Dietary Services #DS-03 Guidelines for meal distribution, and special event meal/snack service. 05/02/2016

Section VII -- Emergency Response

Allegation of Rape or Sexual Assault #ER-01 Procedures of action to take when a patient makes an allegation of rape or sexual assault. 03/31/2014
Critical Incident Stress Management Services #ER-05 To clarify policies and procedures for the use of Critical Incident Stress Management (CISM) services at MSH.  To clarify appropriate activation and use of the CISM Team.


Fire, Emergency, and Disaster Plan #ER-02 Establishment of Fire, Emergency, and Disaster Plan, and communication of information to employees. 01/25/2016
Initiating a Code Silver, Purple, or Yellow at the Main Hospital #ER-07 To provide Montana State Hospital employees, patients, and visitors with a procedure during active shooter events (Code Silver), campus wide lockdowns (Code Purple) and initiating a "Heightened State of Awareness" (Code Yellow) when a potential threat is perceived from outside sources. 7/31/2018
Missing Patients -- Unauthorized Leave #ER-03 Procedures regarding patients who leave the hospital without authorization, including notification process. 6/17/2014
Patient Riot - Emergency Response #ER-06 To specify emergency procedures to be followed in the event of a patient riot on a treatment unit of Montana State Hospital. 06/02/2016
Response and Notification of Authorities in the Event of a Serious Emergency #ER-04 Establishes response procedures in the event of serious emergencies (e.g., unusual or unnatural deaths, serious injuries, rape, assault, suicide, homicide) 07/02/2014

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
Discharge or Conditional Release from Forensic Commitment #FP-09 Clarifies standards, responsibilities, and procedures for the discharge or conditional release of patients under a forensic commitment to Montana State Hospital. 01/25/2016
Forensic (D Unit) Security Procedures #FP-04 To provide for security procedures specific to the Forensic (D Unit) of Montana State Hospital. 09/17/2017
Forensic Involuntary Medications #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. 02/17/2016
Forensic Patient Escape #FP-05 Provide emergency procedures in response to an unauthorized leave or escape of a forensic patient at Montana State Hospital. 11/24/2015
Forensic Review Board #FP-01 Responsibilities and operations of the Forensic Review Board. 05/26/2016
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). 07/03/2014

Section IX -- Health Information

Abbreviations #HI-01 List of approved abbreviations. 06/10/2014
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 designated protection and advocacy system. 04/21/2016
Billing Charges for Photocopies of Health Information #HI-02 Establishes procedures for charging for copies of medical records. 12/01/2014
Charting Rules to Observe #HI-03 General rules for charting. 05/06/2015
Discharge Summary #HI-04 Guidelines for completion of Discharge Summaries. 05/20/2014
Documentation in Progress Notes #HI-05 Progress Note entries. 05/06/2015
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. 10/10/2014
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. 12/30/2013
Guidelines for Release of Information #HI-06 Procedures for releasing information from medical records. 12/03/2014
HIPAA Documentation and Record Retention #HI-18 Addresses documentation and record retention requirements of the Health Insurance Portability and Accountability Act of 1996. 04/22/2014
Medical Records: Access and Security #HI-07 Procedures to control access to medical records and maintain security. 06/03/2014
Mental Disabilities Board of Visitors - Access to Patient Records #HI-09 Access to patient records by Board of Visitors staff 04/21/2016
Notice of Privacy Practices #HI-06 Addresses information that must be contained in the official notice of privacy practices titled "Notice of Use of Private Health Information." 12/30/2013
Patient Request to See, Copy, and/or Amend His/Her Own Chart #HI-11 Procedure for handling patient requests to see or amend their clinical record. 10/10/2014
Protected Health Information Facsimile Transmission #HI-08 Procedures governing sending and receiving medical records information via facsimile (fax) machine. 05/04/2015
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. 08/23/2017

Section X -- Housekeeping/Laundry

Housekeeping Chemicals and Their Safe Use #HL-01 Procedures for use of chemical cleaning compounds. 04/12/2016
Terminal Isolation Room Cleaning #HL-02 Cleaning of isolation rooms. 05/14/2015

Section XI -- Human Resources

Access Control Keys #HR-01 Ensures appropriate access to all hospital areas. 04/14/2016
Assignment of Utilization of Personnel #HR-02 Provides guidelines for the assignment of personnel based on job classification without regard to gender. 10/18/2016
Attendance, Work Hours, and Absence from Work #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. 10/11/2017
Code of Ethics for Employees of Montana State Hospital #HR-05 Employee ethics policy. 11/21/2013
Department of Public Health & Human Services Personnel Policies #HR-20 To ensure applicable guidelines are available to administrative and supervisory staff for use when resolving personnel issues. 10/18/2016
Dress Code Standards #HR-07 Employee dress code. 08/07/2014
Drug and Alcohol Testing Policy for Employees Holding a Commercial Driver's License #HR-08 Ensures fitness for duty by employees in positions that require a Commercial Driver's License (CDL).  This policy is intended to comply with applicable Federal regulations governing workplace anti-drug programs. 10/18/2016
Employee Conduct #HR-06 Provides standards for employee conduct that promote quality patient care and reflect the expectations of the citizens of Montana for public employees who provide care to people with disabilities. 10/18/2016
Employee Recreation Hospital Facilities #HR-09 Establishes guidelines for employee utilization of the hospital recreation facilities. 10/18/2016

Equal Opportunity, Nondiscrimination, and Harassment Prevention DPHHS Policy

DPHHS Policy DPHHS Equal Employment Opportunity, Nondiscrimination, and harassment prevention policy 02/11/2014
Leave Policy #HR-03 Provides uniform guidelines throughout MSH for administering leave requests (e.g., sick leave, annual leave, etc.). 07/14/2014
Occupational Housing Policy #HR-10 Policy regarding the management of employee housing units. 01/27/2014
Patient Americans with Disabilities Act (ADA) Accommodations #HR-25 Outlines the policy and process used by hospital staff to assess a patient's abilities and the steps to take to engage a patient's need for an accommodation pursuant to the Americans with Disabilities Act in the provision of treatment for patients at MSH. 10/18/2016
Per Diem/On-Call Positions #HR-11 Establishes on-call staffing pool. 04/22/2014
Performance Planning and Evaluation #HR-12 Provide for a uniform, consistent method of performance evaluation for employees. 05/08/2014
Personal Cell Phone, Electronic Communication Device Use by Employees #HR-24 To provide guidelines for use of personal cell phone/electronic communication devices by employees in the
workplace.  To ensure the safety and security of the therapeutic treatment environment and to ensure patient and employee privacy and confidentiality.

Probation Requirements MOM Policy

MOM State of Montana employees hired into a designated permanent or seasonal position must successfully complete conditions of probation during a probationary period.  This policy provides minimum standards for administering probation. 08/21/2012
Reimbursement for Damaged Employee Owned Property #HR-13 Delineates employee and employer responsibilities regarding damage to or loss of personal property brought to MSH for use by an employee. 12/11/2015
Sick Leave Abuse #HR-16 Provides uniform guidelines throughout MSH for the prevention of sick leave abuse. 07/21/2014
Verification of Licensure/Certification #HR-17 Procedures to ensure verification of licensure and certification for appropriate hospital employees. 12/30/2013
Volunteer Services #HR-19 Establishes procedures for volunteers working at MSH. 11/8/2017
Workplace Violence and Harassment Prohibited #HR-21 Procedures and guidelines addressing occurrences of workplace violence and harassment. 12/30/2013


Body Piercing and Tattooing Prohibited #IC-17 To minimize risk of infection or other physical or emotional harm to patients from body piercing or tattooing during hospitalization. 01/12/2016
Cleaning of Non-Critical, Reusable Patient Care Equipment #IC-19 To establish a process for the cleaning of non-critical, reusable patient care equipment. 09/05/2014
Employee Health Record & Immunization/Testing Requirements #IC-02 To provide current record of all employee' immunization and tuberculosis screening status and explain immunization and testing requirements for employees. 04/18/2016
Exposure Control Plan #IC-03 Establishes responsibilities to minimize risk of acquiring bloodborne disease due to occupational exposure. 04/18/2016
Glove Use #IC-20 Reduces risk of contamination of health-care workers hands with blood and other body fluids, and to reduce the risk of germ dissemination to the environment and of transmission from the health-care worker to the patient and vice versa, as well as from one patient to the other. 01/12/2016
Guidelines for Isolation Precautions #IC-11 Isolation techniques to prevent the spread of disease. 04/28/2016
Handling of Needles, Sharps, & Razors #IC-04 To provide a safe disposal method for used needles and sharps. 01/12/2016
Handwashing #IC-05 To prevent contamination by bloodborne pathogens.  Handwashing is the single most effective deterrent to the spread of infection.


Health Care Associated Infections #IC-13 The tracking of health care associated infection is necessary to monitor overall effectiveness of Infection Prevention practices. 01/12/2016
Hepatitis B Vaccination Program #IC-06 Provision of Hepatitis B vaccines to employees. 08/04/2017
Infection Control - Care of Contaminated Articles #IC-07 Identifies methods for handling clothing and linen contaminated with bloodborne pathogen, other disease causing organisms, or parasites.


Infection Prevention and Control Plan #IC-09 Describes MSH Infection Control Program. 07/31/2018
Infection Report #IC-10 Provides an active system of reporting patient infections, evaluating treatment outcomes, and maintaining of records related to hospital acquired infections. 05/25/2017
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. 06/10/2015
Pediculosis/Scabies #IC-18 To promptly diagnose and treat a patient that presents with pediculosis and scabies. 09/05/2014
Personal Protective Equipment #IC-14 Procedures to assure the availability of personal protective equipment and training in proper use. 02/24/2014
Standard Precautions #IC-15 Describes procedures for prevention of exposure to bloodborne pathogens. 05/12/2014
Tuberculosis Surveillance for Patients #IC-16 Guidelines for TB screening of MSH patients 06/02/2016