Montana Montana State Hospital
Policy Manual -- Volume II

Table of Content
June 20, 2020

Policy Title

Policy Number


Last Issue Date

Section XIII -- Medical Staff

Credentialing and Privileging MS-01 Defines procedures for credentialing and privileging of physicians, APRNs, and/or CNSs, and dentists 06/17/2020
Employee Healthcare Services MS-04 To specify circumstances which Montana State Hospital Medical Staff may provide healthcare services to other Hospital Employees. 05/14/2019
Licensed Independent Practitioner On-Call Coverage MS-02 Provides psychiatric and primary care licensed practitioner coverage after hours, holidays, and weekends. 06/01/2020
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. 06/05/2020
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. 04/03/2020

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.


Nursing Assessment 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. 04/06/2020
Pharmacy Night Locker NS-05 Establishes a night locker available for use by licensed nurses to obtain medications for immediate therapeutic use when the Pharmacy is closed or when a medication needs to be administered as soon as possible. 03/12/2020

Section XV -- Patient Rights

Informed Consent for Treatment PR-02 Establishes guidelines for obtaining and documenting informed consent for treatment from patients and guardians. 06/08/2020
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

Abdominal Thrusts PH-16 Abdominal thrusts, also known as the "Heimlich Maneuver," are a technique to relieve choking in a responsive victim. 09/30/2019
Admission/Annual History and Physical PH-06 Provide guidelines for assessing patients' medical needs while they are at Montana State Hospital. 06/25/2020
Adverse Drug Reaction Reporting PH-10 Procedures for reporting adverse drug reactions. 11/08/2017
Automated External Defibrillator (AED) PH-14 Provides defibrillation for a person who is in cardiac arrest and ventricular fibrillation. 09/30/2019
Cardio-Pulmonary Resuscitation (CPR) PH-15 Ensures persons receive an appropriate and timely response to clinical emergency situations based on best practice recommendations. 08/30/2019
Death and Autopsy PH-01 Procedures to be followed upon the death of a patient. 02/01/2018
Dietary Supplement PH-02 Establishes a mechanism to ensure the patients at MSH receive medications which are proven to be both safe and effective as set forth by FDA standards. 4/10/2020
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.



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. 06/01/2020
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 Ensures any patient receiving surgery, dental surgery, or invasive medical procedures will be fully informed. 06/19/2020
Respiratory Therapy Services PH-08 Provision of Respiratory Therapy Services. 05/14/2019
Surgical Procedures, Use of Anesthesia and Blood Products at Montana State Hospital PH-09 Describes limited surgical procedures provided at MSH. 05/14/2019

Section XVII -- Psychology Services

Psychological Evaluation PGS-01 Describe psychological evaluation services at Montana State Hospital 05/30/2019

Section XVIII -- Psychiatric Services

Clozaril Standard Titration Schedules PS-01 Protocol for prescribing Clozaril. 06/03/2020
Involuntary Medications PS-02 Procedures for involuntary medication administration as allowed under Montana Statute. 06/02/2020
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 Provides guidelines for assessing patients' psychiatric needs while they are at MSH. 06/19/2020
Standing Order: Drug Guidelines for Lab PS-05 Ensure standardization for testing patients who are taking anticonvulsant, antipsychotic, or other specific drugs which require laboratory work. 4/28/2020

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.

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.  06/01/2020
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.


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. 06/29/2020
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 To comply with the SMDA Act of 1990 by providing information to the FDA and/or manufacturer regarding medical device problems to allow for appropriate action to be taken. 06/19/2020
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 Establishes an AIMS assessment process for MSH patients. 06/02/2020
Advance Directives (Declarations) TX-02 Provides procedures for informing patients of their right to issue an advance directive and to receive assistance from staff in the matter. 06/19/2020
Allegations of Abuse or Neglect TX-17 Procedures to be taken when allegations of patient abuse or neglect occur. 03/26/2019
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. 03/12/2020
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. 06/25/2020
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. 06/12/2020
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-Facility Transfers TX-08 Establishes transfer procedures for use when a clinical determination is made that a patient may be more appropriately served on another treatment program. 06/12/2020
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


Ensures appropriate review and oversight of non-standard treatment interventions proposed by clinical staff at Montana State Hospital.

Occupational Therapy Services TX-38 Provides procedural guidelines governing the administration of Occupational Therapy Services and it integration into the master treatment plan of MSH patients. Ensures appropriate therapeutic occupational therapy services are provided in a timely manner. 3/25/2020
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, Trades and Exchanges TX-28 General policy to address issues related to buying, selling, trading, or gift giving.


Patient Sexual Behavior TX-11 Provides guidelines and procedures for staff when confronted with issues related to the sexual behavior of hospital patients. 05/18/2020
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.


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. 08/30/2019
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. 03/25/2020
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.