Montana State Hospital
Policy Manual -- Volume I

Table of Contents
  February 3, 2021

Policy Title




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. 06/18/2020

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. 03/26/2020
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. 03/28/2019
Firearms Carried by Law Enforcement Officials ADM-02 Prohibits law enforcement officers from carrying fire arms into patient occupied buildings. 01/07/2019
Governance ADM-09 Identifies responsibilities for governance, management, and control of Montana State Hospital. 03/11/2020
Parking Policy ADM-11 To outline procedures for employees, visitor, and handicapped parking on the Montana State Hospital campus 06/19/2020
Patient Visitation ADM-08 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. 06/19/2020
Pharmaceutical Industry Representatives ADM-10 To establish guidelines for interactions between staff of Montana State Hospital and Pharmaceutical Industry Representatives. 03/26/2019
Policy Development, Revision, Format, Approval, and Distribution ADM-04 Describes a systematic procedure for development, review, update approval, and dissemination of hospital policy/procedure. 06/19/2020
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. 06/01/2020
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. 05/22/2020
Front Desk Change Fund BS-07 Establishes procedures for the front desk change fund for use in the sale of visitor meal tickets. 05/22/2020
Imprest Cash Account BS-02 Procedures for the operation of the Imprest Cash Account (petty cash fund). 05/22/2020
Interagency Charges for Photocopies BS-06 DPHHS agencies utilizing MSH copy machines will be charged an established and reasonable fee per copy. 01/07/2019
Operation of Patient Deposit for MSH BS-03 Establishes guidelines for operation of the MSH Patient Account Office. 06/03/2020
Patient Travel BS-04 Procedure for providing funds for bus or airline tickets for patients. 05/22/2020
Reimbursement for Damage Destruction of Hospital Property BS-05 An organized procedure to provide reimbursement for the destruction or damage of hospital property. 05/22/2020
Revolving Cash Checking (Contingency) Account BS-09 Establish policy and procedure under which a Contingency Check is to be utilized in lieu of a pay voucher. 05/22/2020
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 Describes Montana State Hospital's Nutritional Assessment and Consultation processes; thereby providing guidelines for the identification and treatment of patients at nutritional risk. 4/29/2020
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. 01/18/2019
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.


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. 07/31/2018
Missing Patients -- Unauthorized Leave ER-03 Procedures regarding patients who leave the hospital without authorization, including notification process. 04/06/2020
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
Use of Protective Shield ER-08 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. 6/29/2020

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. 06/12/2020
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. 03/25/2019
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 a reasonable charge for photocopying and/or scanning materials in accordance with DPHHS policy. 4/29/2020
Charting Rules to Observe HI-03 General rules for charting. 01/31/2019
Discharge Summary HI-04 Guidelines for completion of Discharge Summaries.


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. 01/29/2019
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. 05/01/2019
Guidelines for Release of Information HI-06 Establishes safeguards to preserve the privacy and confidentiality of patient information. May 1, 2020
HIPAA Documentation and Record Retention HI-18 Addresses documentation and record retention requirements of the Health Insurance Portability and Accountability Act of 1996. 01/29/2019
Medical Records: Access and Security HI-07 Procedures to control access to medical records and maintain security. 05/06/2019
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." 05/14/2019
Patient Request to See, Copy, and/or Amend His/Her Own Chart HI-11 Maintains standards and procedures for release of information to patients requesting to view, copy, or amend their medical record per Montana Code Annotated. 5/22/2020
Protected Health Information Facsimile Transmission HI-08 Procedures governing sending and receiving medical records information via facsimile (fax) machine. 02/15/2019
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
Attendance, Work Hours, and Absence from Work HR-18 Delineates length of work hours and break periods. 01/15/2019
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
Dress Code Standards HR-07 Employee dress code. 01/02/2021
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. 01/15/2019
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
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
Performance Planning and Evaluation HR-12 Provide for a uniform, consistent method of performance evaluation for employees. 01/10/2019
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
Verification of Licensure/Certification HR-17 Procedures to ensure verification of licensure and certification for appropriate hospital employees. 09/06/2019
Volunteer Services HR-19 Establishes procedures for volunteers working at MSH. 11/8/2017
Worker's Compensation HR-21 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. 03/19/2020


Antimicrobial Stewardship Program IC-10 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. 02/07/2019
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. 09/30/2019
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. 11/26/2019
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 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. 5/8/2020
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.


Healthcare Associated Infections IC-13 The tracking of health care associated infection is necessary to monitor overall effectiveness of Infection Prevention practices. 06/01/2020
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. 02/02/2021
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/Pthirus/Scabies/Bed Bugs IC-18 To promptly diagnose and treat a patient which presents with pediculosis, Pthirus, scabies or bed bugs. 6/29/2020
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. 04/06/2020
Tuberculosis Surveillance for Patients IC-16 Provides guidelines for tuberculosis surveillance. 4/29/2020