| |
Policy #
|
Description
|
Last Issue Date
|
Section XIII -- Medical Staff
|
| Credentialing and Privileging |
#MS-01 |
Defines procedures for credentialing and privileging of physicians and dentists |
08/25/2016 |
| Employee Healthcare Services |
#MS-04 |
To specify circumstances which Montana State Hospital Medical Staff may provide healthcare services to other Hospital Employees. |
10/09/2014 |
| Licensed Independent Practitioner On-Call Coverage |
#MS-02 |
Provision of on-call physician/psychiatrist coverage |
12/25/2014 |
| Licensed Independent Practitioner Standards of Practice and Supervision |
#MS-05 |
To provide standard of practice for psychiatric and primary care Licensed Independent Practitioners at Montana State Hospital to ensure compliance with state and federal regulations. |
02/17/2017 |
| Licensed Independent Practitioner Use of Hospital DEA Number |
#MS-06 |
Defines when a Licensed Independent Practitioner may use the Hospital DEA registration number |
02/14/2019 |
| Medication Order Standards |
#MS-03 |
To establish standards for Licensed Independent Practitioners (LIPs) to write medication orders on Physician's Order forms to ensure compliance with standards and reduce errors. |
11/25/2014 |
Section XIV -- Nursing Services
|
| Medication Administration and Safe Handling, Principles of |
#NS-02 |
To ensure the safe, appropriate, and accurate administration and handling of medications. |
09/18/2017 |
| Medication Error Reporting |
#NS-03 |
To describe the procedures of reporting medication errors, to ensure accurate and appropriate use of medications. |
01/18/2019
|
| Nursing Assessment and Diagnosis |
#NS-03 |
To identify and prioritize the appropriate nursing diagnosis which provide the focus for the development of the patient's plan of care and discharge plan. |
12/11/2015 |
| Pharmacy Night Locker |
#NS-05 |
Addresses access to medications at night. |
10/09/2014 |
Section XV -- Patient Rights
|
| Informed Consent for Treatment |
#PR-02 |
Procedures for obtaining a patient's informed consent for treatment. |
08/25/2016 |
| Patient Grievance Procedure |
#PR-03 |
Describes the Patient Grievance Process. |
09/21/2018 |
| Patient Rights and Grievance Procedure Information |
#PR-04 |
Procedure for presenting information to patients on their Rights and Grievance Procedure. |
02/12/2016 |
| Voting Rights of Patients |
#PR-05 |
Procedures for providing assistance to patients wishing to exercise their right to vote. |
07/03/2014 |
Section XVI -- Physical Health
|
| Admission/Annual History and Physical |
#PH-06 |
Provide guidelines for assessing patients' medical needs while they are at Montana State Hospital. |
12/15/2015 |
| Adverse Drug Reaction Reporting |
#PH-10 |
Procedures for reporting adverse drug reactions. |
11/08/2017 |
| Death and Autopsy |
#PH-01 |
Procedures to be followed upon the death of a patient. |
02/01/2018 |
| Dietary Supplement |
#PH-02 |
To establish a mechanism to ensure the patients at MSH receive medications that are proven to be both safe and effective as set forth by FDA standards. |
02/24/2014 |
| Informing/Communicating Changes in Patient's Condition |
#PH-03 |
Responsibility for providing information about changes in physical health to family members. |
06/01/2018 |
| Medical Clinic Services |
#PH-04 |
To provide quality Medical/Dental healthcare with continuity of treatment for patients and to prevent spread of communicable disease among patients and employees. |
12/11/2015 |
| Medical Emergency Response -- Initiating a "Code Blue" |
#PH-11 |
To provide a plan for response to medical emergencies |
09/14/2018 |
| Medical Marijuana Possession |
#PH-13 |
To describe procedures for handling medical marijuana legally in the possession of persons-served at the time of admission. |
12/09/2015
|
| 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. |
06/03/2014 |
| Organ and Tissue Donation |
#PH-05 |
To clarify issues regarding potential organ, tissue, and eye donations from MSH patients. MSH will not routinely attempt to identify potential organ and tissue donations. |
05/22/2015 |
| Procedure for Obtaining Informed Consent for Medical and Surgical Procedures |
#PH-07 |
Addresses informed consent for surgical procedures. |
04/21/2016 |
| Respiratory Therapy Services |
#PH-08 |
Provision of Respiratory Therapy Services. |
05/16/2014 |
| Surgical Procedures, Use of Anesthesia and Blood Products at Montana State Hospital |
#PH-09 |
Describes limited surgical procedures provided at MSH. |
06/17/2014 |
Section XVII -- Psychology Services
|
| Psychological Evaluation |
#PGS-01 |
Describe psychological evaluation services at Montana State Hospital |
07/28/2015 |
Section XVIII -- Psychiatric Services
|
| Clozaril Standard Titration Schedules |
#PS-01 |
Protocol for prescribing Clozaril. |
09/8/2016 |
| Involuntary Medications |
#PS-02 |
Procedures for involuntary medication administration as allowed under Montana Statute. |
12/11/2014 |
| Licensed Independent Practitioner Review of Patient Medication Regimen |
#PS-03 |
Procedures for meeting requirements of M.C.A. 53-21-145 which require weekly review of medication. |
05/24/2018 |
| Psychiatric Assessments |
#PS-04 |
Psychiatric assessment procedures. |
09/05/2014 |
| Standing Order: Drug Guidelines for Lab |
#PS-05 |
Standardized laboratory tests for patients taking anticonvulsant and antipsychotic medications. |
05/13/2014 |
Section XIX -- Quality Improvement
|
| Death Review |
#QI-01 |
Procedures for reviewing patient deaths to evaluate quality of care. |
02/06/2017 |
| Quality Improvement Plan |
#QI-02 |
Development of Annual Quality Improvement Plan. |
12/11/2015 |
| Review of Seclusion and Restraint Incidents |
#QI-04 |
To provide a post-incident review process for all restraint and seclusion interventions.
|
12/09/2015 |
| Serious Adverse Events |
#QI-05 |
Guidelines for conducting a risk-prevention analysis in response to significant or sentinel events. |
06/01/2018 |
Section XX -- Radiology Department
|
| Exposure Badges for the Radiology Department |
#RD-01 |
To identify methods for preventing over exposure to ionizing radiation. |
03/16/2017 |
| Infection Control for the Radiology Department |
#RD-02 |
To identify methods for preventing the spread of infection through the radiology department, personnel, or equipment. |
03/16/2017 |
| Inspection of Radiology Equipment Department |
#RD-03 |
To identify methods for yearly inspection of radiology equipment. |
03/16/2017 |
| Quality Assurance for the Radiology Department |
#RD-04 |
To enable the radiology department to provide the highest quality of diagnostic care to MSH patients; to assure the provision of consistently optimal patient care through evaluation of the clinical performance of all technologists in the department and to reduce or eliminate problems identified by the facility and medical staff, and by evaluation of current activities. |
03/16/2017 |
| Radiologic Imaging Equipment Usage |
#RD-05 |
Provide radiology services to serve patients at MSH by providing only qualified medical personnel to operate the imaging equipment. |
03/16/2017 |
| Radiology |
#RD-06 |
To ensure MSH patients receive the highest level of radiologic services. |
03/16/2017 |
| Radiology Report Retention |
#RD-07 |
To ensure retention of radiology reports. |
03/16/2017 |
| Radiology Report Turnaround Time |
#RD-08 |
Ensure radiologist reports are received within a reasonable time period to assure quality patient care. |
03/16/2017 |
| Safety Policy for the Radiology Department |
#RD-09 |
To provide for patient and staff safety during radiologic procedures at MSH. MSH is committed to an effective radiation protection program to eliminate unnecessary exposures to radiation and to reduce all exposures to levels that "Are as Low As Reasonably Achievable" (ALARA). |
03/16/2017 |
| Scope of Services for the Radiology Department |
#RD-10 |
To define the scope of services provided by the MSH radiology department and to ensure that all patients treated will receive high quality care in an expedient and professional manner. |
03/16/2017 |
| Service Hours for the Radiology Department |
#RD-11 |
Provide radiology services to serve patients at MSH. |
07/21/2017 |
Section XXI -- Rehabilitation Therapy Services
|
| Recreational Therapy Assessment |
#RTS-03 |
Provides procedural guidelines for the provision of Recreational Therapy Assessment and its integration into the Treatment Plan of Montana State Hospital patients. |
11/19/2015 |
| Substance-Related and Addictive Disorders Evaluation |
#RTS-02 |
To provide guidelines for substance-related and addictive disorders evaluations at Montana State Hospital. |
12/11/2015 |
| Vocational Assessment |
#RTS-05 |
To provide procedural guidelines governing the provision of vocational assessments and integration of the results into treatment, discharge, and aftercare plans for patients of Montana State Hospital. |
11/25/2015
|
Section XXII -- Safety
|
| Contraband and Searches |
#SF-02 |
Defines contraband and establishes search procedures. |
01/25/2016 |
| Door Stop Usage |
#SF-09 |
Outlines the use of door stops in patient occupied areas of Montana State Hospital. |
12/11/2015 |
| 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. |
08/23/2017 |
| Incident Response and Reporting |
#SF-04 |
Describes response procedures for different types of incidents and completion of the Incident Report Form |
12/11/2015 |
| 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 |
04/21/2016 |
| Medical Device Reporting |
#SF-05 |
Procedures for meeting FDA requirements for reporting problems with medical devices |
12/09/2015 |
| Safety Committee |
#SF-03 |
To address all areas of hospital operation to ensure and improve safety for all patients, staff and visitors. |
07/30/2015 |
| Workman's Compensation |
#SF-07 |
Identifies responsibilities in the event of a work-related injury that results in Worker's Compensation benefits. |
12/11/2015 |
Section XXIII -- Social Services
|
| Initial and Annual Social Assessments |
#SS-01 |
Completion of Social Work Assessments. |
04/13/2016 |
| Special Education Services |
#SS-02 |
To ensure patients up to the age of 19 at Montana State Hospital have been assessed for special education services and provided these services. |
08/05/2015 |
Section XXIV -- Staff Development
|
| Tour Requests & Procedures |
#SD-01 |
Procedures for conducting tours of MSH for educational groups, the media, etc. |
04/18/2016 |
| Student Internships |
#SD-02 |
To establish policy and procedures outlining the expectations of student internships at Montana State Hospital. |
11/24/2015 |
Section XXV -- Support Services
|
| Preventative Maintenance Program |
#SPS-01 |
Describes preventative maintenance program. |
08/24/2017 |
Section XXVI -- Treatment
|
| Abnormal Involuntary Movement Scale (AIMS) Examination for Tardive Dyskinesia |
#TX-01 |
AIMS assessment procedures. |
09/08/2016 |
| Advance Directives (Declarations) |
#TX-02 |
Advance Directives. |
07/03/2014 |
| Allegations of Abuse or Neglect |
#TX-17 |
Procedures to be taken when allegations of patient abuse or neglect occur. |
12/1/2015 |
| Animal Assisted Therapy |
#TX-33 |
Provide guidelines for the implementation of animal assisted therapy as a part of treatment and rehabilitation programs provided by Montana State Hospital. |
11/24/2015 |
| Close Observation |
#TX-34 |
To promote safety of the specified patient when acute behavioral/physical problems are present. |
05/19/2016 |
| 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. |
05/24/2018 |
| Escorting Patients Off Campus |
#TX-27 |
Provides for safety and security when escorting patients off campus. |
01/18/2019 |
| 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. |
09/18/2017 |
| Guardianship |
#TX-07 |
Procedures for guardianship. |
12/11/2015 |
| Institutional Review Board |
#TX-24 |
Establishes an Institutional Review Board (IRB) to review and approve research activities at MSH involving or affecting hospital patients. |
04/20/2016 |
| Interpreter Services |
#TX-20 |
Guidelines for interpreter services for non-English or limited English speaking patients, or for a patient with a hearing impairment. |
11/24/2015 |
| Intra-Campus Transfers |
#TX-08 |
Transfer of patients between treatment programs. |
08/01/2012 |
| Methadone and Buprenorphine Authorized Use for Opioid Dependence |
#TX-36 |
Defines the authorized use of methadone and buprenorphine products for the treatment or maintenance of opioid dependence when a patient is admitted to the hospital with another underlying medical condition. |
02/14/2019 |
|
Non-Standard Treatment Interventions
|
#TX-26 |
To ensure appropriate review and oversight of non-standard treatment interventions proposed by clinical staff at Montana State Hospital.
|
05/22/2015 |
| Pain Assessment, Management and Safe Use of Opioids |
#TX-35 |
To assess and manage a patient's pain while minimizing risks associated with treatment. To minimize the risk of adverse events, abuse, and addiction evidenced-based practices are to be used when treating acute and chronic pain with opioids. |
01/31/2019 |
| Pastoral Services |
#TX-09 |
Montana State Hospital seeks to provide holistic care of each patient's body, mind, and spirit from the time of admission through discharge. |
04/13/2016 |
| Patient Assessment |
#TX-10 |
General policy regarding patient assessment procedures. |
06/01/2018 |
| Patient Gift Giving |
#TX-28 |
General policy to address issues related to buying, selling, trading, or gift giving. |
04/08/2014 |
| Patient Sexual Behavior |
#TX-11 |
Provides guidelines and procedures for staff when confronted with issues related to the sexual behavior of hospital patients. |
12/11/2015 |
| Patients' Allocated Monthly Spending Allowance |
#TX-19 |
To provide guidelines for patients regarding utilization of their financial resources. |
11/19/2015 |
| Suicide Precautions |
#TX-14 |
Suicide precautions. |
04/26/2016 |
| Treatment and Leisure Pass |
#TX-04 |
To provide guidelines for patients attending on campus treatment and leisure activities. |
07/25/2017
|
| Treatment Plan |
#TX-12 |
Establish policies and procedures for the initiation, development, implementation, and review of treatment plans for patients of Montana State Hospital. |
11/25/2015 |
| Unauthorized Leave Precautions |
#TX-23 |
Standard procedures for use of unauthorized leave precautions. |
04/19/2016 |
| 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. |
06/01/2015 |
| 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. |
05/19/2016 |
| Use of Seclusion and Restraint |
#TX-16 |
To seek to care for each person in the least restrictive manner possible while protecting the safety, rights, and dignity of all parties involved. |
11/15/2013 |
| Videotaping |
#TX-29 |
To establish guidelines for videotaping Montana State Hospital staff treatments or interventions with patients. |
11/25/2015 |
| Visitation with Personal Pets |
#TX-21 |
To provide guidelines when patients request to have personal visits from people bringing personal pets to the Montana State Hospital Campus.
|
07/30/2015 |