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Policy Manual Volume 2

Montana Montana State Hospital
Policy Manual -- Volume II

Table of Contents
February 15, 2019


Policy #


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.


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.



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.

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.


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


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

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.


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.