Section I -- Admission and Discharge
||Establishes criteria and procedures for admission to MSH
|Discharge or Conditional Release from Civil Commitment
||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.
||Discharge planning procedures to ensure that discharge planning begins at the time of admission and is updated throughout the duration of hospitalization.
|Interstate Compact on Mental Health
||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.
|Management of Patient's Personal Effects
||Provides instruction for management of personal items belonging to patients of Montana State Hospital
||To establish procedures between MSH and community providers for pre-placement visits and pre-placement visits with subsequent discharges.
Section II -- Administration
|Access to Patient & Treatment Areas by Designated Protection & Advocacy System
||To assure that representatives of the protection and advocacy system designated by the State of Montana are provided reasonable unaccompanied access to MSH patients.
|Access to Patient & Treatment Areas by Mental Disabilities Board of Visitors Staff
||To assure that representatives of the Mental Disabilities Board of Visitors are provided access to MSH patients to perform their duties.
||Procedures for managing contracted services
|Description of Services
||Defines MSH's role in providing psychiatric services.
|Firearms Carried by Law Enforcement Officials
||Prohibits law enforcement officers from carrying fire arms into patient occupied buildings.
||Identifies responsibilities for governance, management, and control of Montana State Hospital.
||To outline procedures for employees, visitor, and handicapped parking on the Montana State Hospital campus
||Provides guidelines for visiting Montana State Hospital patients. Visits from family members, friends, and other supportive individuals may enhance the treatment provided to patients and increase the prospect for the patient's successful return to the community.
|Pharmaceutical Industry Representatives
||To establish guidelines for interactions between staff of Montana State Hospital and Pharmaceutical Industry Representatives.
|Policy Development, Revision, Format, Approval, and Distribution
||Describes a systematic procedure for development, review, update approval, and dissemination of hospital policy/procedure.
|Security Camera System
|To provide guidance regarding the security camera system in Montana State Hospital facilities and the maintenance and use of records generated by the system.
|Tobacco and Nicotine
To promote a safe and healthy environment on the Montana State Hospital Campus.
Section III -- Business Services
|Disposition of State Property
||Procedures regarding the disposition on non-expendable state property.
|Employee Charges for Photocopies
||To ensure photocopy expenses incurred at MSH are paid.
|Front Desk Change Fund
||Establishes procedures for the front desk change fund for use in the sale of visitor meal tickets.
|Imprest Cash Account
||Procedures for the operation of the Imprest Cash Account (petty cash fund).
|Interagency Charges for Photocopies
||DPHHS agencies utilizing MSH copy machines will be charged an established and reasonable fee per copy.
|Operation of Patient Deposit for MSH
||Establishes guidelines for operation of the MSH Patient Account Office.
||Procedure for providing funds for bus or airline tickets for patients.
|Reimbursement for Damage Destruction of Hospital Property
||An organized procedure to provide reimbursement for the destruction or damage of hospital property.
|Revolving Cash Checking (Contingency) Account
||Establish policy and procedure under which a Contingency Check is to be utilized in lieu of a pay voucher.
|Transitional Funds - Requests and Approval
||To provide procedures for requesting and authorizing funds for the purpose of assisting people in transitioning from Hospital care to community placements.
Section IV -- Commitment/Recommitment Petitions
|Petitions for Commitment/Recommitment, and Receiving and Recording Hearings/Orders
||Procedure for filing commitment or recommitment petitions.
Section V -- Dental Services
|Anesthesia Use in Dental Procedures
||Procedures for administration of anesthesia for dental procedures.
||Procedures for maintaining dental records.
||Procedures for the provision of routing and emergency dental services for MSH patients.
Section VI -- Dietary Services
|Clinical Nutrition Services
||Describes Montana State Hospital's Nutritional Assessment and Consultation processes; thereby providing guidelines for the identification and treatment of patients at nutritional risk.
|Dietary Glove Use
||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.
||Procedure to inform patients of drug-food interactions which require dietary modifications.
|Provision of Dietary Services
||Guidelines for meal distribution, and special event meal/snack service.
Section VII -- Emergency Response
|Allegation of Rape or Sexual Assault
||Procedures of action to take when a patient makes an allegation of rape or sexual assault.
|Critical Incident Stress Management Services
||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
||Establishment of Fire, Emergency, and Disaster Plan, and communication of information to employees.
|Initiating a Code Silver, Purple, or Yellow at the Main Hospital
||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.
|Missing Patients -- Unauthorized Leave
||Procedures regarding patients who leave the hospital without authorization, including notification process.
|Patient Riot - Emergency Response
||To specify emergency procedures to be followed in the event of a patient riot on a treatment unit of Montana State Hospital.
|Response and Notification of Authorities in the Event of a Serious Emergency
||Establishes response procedures in the event of serious emergencies (e.g., unusual or unnatural deaths, serious injuries, rape, assault, suicide, homicide)
|Use of Protective Shield
||To define the accepted use of a protective shield when there is a potential threat of assault. To care for each patient in the least restrictive manner possible while protecting the safety, rights and dignity of all parties involved.
Section VIII -- Forensic Program
|D Unit Outdoor Exercise Yard and Courtyards
||Establishes guidelines for use of the D Unit Outdoor Exercise Yard and
|Discharge or Conditional Release from Forensic Commitment
||Clarifies standards, responsibilities, and procedures for the discharge or conditional release of patients under a forensic commitment to Montana State Hospital.
|Forensic (D Unit) Security Procedures
||To provide for security procedures specific to the Forensic (D Unit) of Montana State Hospital.
|Forensic Involuntary Medications
||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.
|Forensic Patient Escape
||Provide emergency procedures in response to an unauthorized leave or escape of a forensic patient at Montana State Hospital.
|Forensic Review Board
||Responsibilities and operations of the Forensic Review Board.
|Security Restraints for Patients on Forensic Commitments
||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).
Section IX -- Health Information
||List of approved abbreviations.
|Access to Patient Records by Protection and Advocacy System
||To establish procedures for providing access to patient records by employees and authorized agents of designated protection and advocacy system.
|Billing Charges for Photocopies of Health Information
||Establishes a reasonable charge for photocopying and/or scanning materials in accordance with DPHHS policy.
|Charting Rules to Observe
||General rules for charting.
||Guidelines for completion of Discharge Summaries.
|Documentation in Progress Notes
||Progress Note entries.
|Employee Access to Protected Health Information
||Addresses MSH employee access to various levels of Protected Health Information (PHI) as necessary to conduct their work.
|Employee Sanctions for Releases of Protected Health Information
||Addresses disciplinary action to be taken toward MSH employees who release PHI in violation of HIPAA Privacy Rules and DPHHS/MSH policies.
|Guidelines for Release of Information
||Establishes safeguards to preserve the privacy and confidentiality of patient information.
||May 1, 2020
|HIPAA Documentation and Record Retention
||Addresses documentation and record retention requirements of the Health Insurance Portability and Accountability Act of 1996.
|Medical Records: Access and Security
||Procedures to control access to medical records and maintain security.
|Mental Disabilities Board of Visitors - Access to Patient Records
||Access to patient records by Board of Visitors staff
|Notice of Privacy Practices
||Addresses information that must be contained in the official notice of privacy practices titled "Notice of Use of Private Health Information."
|Patient Request to See, Copy, and/or Amend His/Her Own Chart
||Maintains standards and procedures for release of information to patients requesting to view, copy, or amend their medical record per Montana Code Annotated.
|Protected Health Information Facsimile Transmission
||Procedures governing sending and receiving medical records information via facsimile (fax) machine.
|Records of Persons Admitted on Emergency Detention or Court Ordered Detention Status
||Identifies essential information to be entered into the medical record for emergency detention or court ordered admissions.
Section X -- Housekeeping/Laundry
|Housekeeping Chemicals and Their Safe Use
||Procedures for use of chemical cleaning compounds.
|Terminal Isolation Room Cleaning
||Cleaning of isolation rooms.
Section XI -- Human Resources
|Access Control Keys
||Ensures appropriate access to all hospital areas.
|Attendance, Work Hours, and Absence from Work
||Delineates length of work hours and break periods.
|Borrowing of Hospital Supplies and/or Equipment
||Prohibits loaning of MSH supplies or equipment to employees, groups, or community agencies for personal use.
|Dress Code Standards
||Employee dress code.
|Drug and Alcohol Testing Policy for Employees Holding a Commercial Driver's License
||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.
||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.
|Employee Recreation Hospital Facilities
||Establishes guidelines for employee utilization of the hospital recreation facilities.
Equal Opportunity, Nondiscrimination, and Harassment Prevention DPHHS Policy
||DPHHS Equal Employment Opportunity, Nondiscrimination, and harassment prevention policy
|Occupational Housing Policy
||Policy regarding the management of employee housing units.
|Patient Americans with Disabilities Act (ADA) Accommodations
||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.
|Performance Planning and Evaluation
||Provide for a uniform, consistent method of performance evaluation for employees.
|Personal Cell Phone, Electronic Communication Device Use by Employees
||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
||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.
|Reimbursement for Damaged Employee Owned Property
||Delineates employee and employer responsibilities regarding damage to or loss of personal property brought to MSH for use by an employee.
|Verification of Licensure/Certification
||Procedures to ensure verification of licensure and certification for appropriate hospital employees.
||Establishes procedures for volunteers working at MSH.
||Identifies responsibilities in the event of a work-related injury resulting in Worker's Compensation benefits. Establishes a process for employees injured at work to return to work in a limited capacity.
Section XII - INFECTION CONTROL
|Antimicrobial Stewardship Program
||To achieve optimal clinical outcomes related to antimicrobial use while minimizing toxicity and other adverse events, as the emergence of antimicrobial-resistant organisms. By providing an active system of reporting patient infections, evaluating treatment outcomes, and maintaining records related to hospital acquired infections.
|Body Piercing and Tattooing Prohibited
||To minimize risk of infection or other physical or emotional harm to patients from body piercing or tattooing during hospitalization.
|Cleaning of Non-Critical, Reusable Patient Care Equipment
||To establish a process for the cleaning of non-critical, reusable patient care equipment.
|Employee Health Record & Immunization/Testing Requirements
||To provide current record of all employee' immunization and tuberculosis screening status and explain immunization and testing requirements for employees.
|Exposure Control Plan
||Establishes responsibilities to minimize risk of acquiring bloodborne disease due to occupational exposure.
||Reduces the risk of contamination of health care workers' hands with blood and other bodily fluids, and reduces the risk of germ dissemination between health care workers, patients, and the environment.
|Guidelines for Isolation Precautions
||Isolation techniques to prevent the spread of disease.
|Handling of Needles, Sharps, & Razors
||To provide a safe disposal method for used needles and sharps.
||To prevent contamination by bloodborne pathogens. Handwashing is the single most effective deterrent to the spread of infection.
|Healthcare Associated Infections
||The tracking of health care associated infection is necessary to monitor overall effectiveness of Infection Prevention practices.
|Hepatitis B Vaccination Program
||Provision of Hepatitis B vaccines to employees.
|Infection Control - Care of Contaminated Articles
||Identifies methods for handling clothing and linen contaminated with bloodborne pathogen, other disease causing organisms, or parasites.
|Infection Prevention and Control Plan
||Describes MSH Infection Control Program.
|Management of an Employee with an Occupational Exposure to a Bloodborne Pathogen
||Procedures to be taken in the event of an accidental exposure to bloodborne pathogens.
||To promptly diagnose and treat a patient which presents with pediculosis, Pthirus, scabies or bed bugs.
|Personal Protective Equipment
||Procedures to assure the availability of personal protective equipment and training in proper use.
||Describes procedures for prevention of exposure to bloodborne pathogens.
|Tuberculosis Surveillance for Patients
||Provides guidelines for tuberculosis surveillance.