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Montana Mental Health
Nursing Care Center

Policy Manual

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Section

Title/Content

Date Issued or Revised

    Table of Contents 05/12/12
     
100  Administration   
  101 Mission Statement 10/10/13
  102 Organizational Chart 10/10/13
  102 Attachment 1 Organizational Chart 10/10/13
  103 Policy Procedure 10/10/13
  104 Communication with News Media 10/10/13
  105 Superintendent Absence 10/10/13
  107 Solicitation 10/10/13
  111 Elopement Risk 10/10/13
  112 Missing Persons 10/10/13
  112 Attachment 1 Instructions For Conduction A Search For A Missing Persons 10/10/13
  112 Attachment 2 Search Map 10/10/13
  113 Response to Violent Crime or Suicide 10/10/13
  118 Resident / Employee Transactions 10/10/13
  118 Attachment 1 Resident  /Employee Transaction Form 10/10/13
  119 Sexual Harassment 10/10/13
  119 Attachment 1 Equal Employment Oppertunity, Non-Discrimination and Harrassment Prevention 10/10/13
  120 Emergency Plan 10/10/13
  120 Attachment 1 Emergency Telephone Numbers 10/10/13
  120 Attachment 1a Emergency Telephone Numbers 10/10/13
  120 Attachment 2 General Orientation to Organization 10/10/13
  120 Attachment 3 Facility Map 10/10/13
  120 Attachment 4 Water Service 10/10/13
  120 Attachment 5 Strike Contingency Plan 10/10/13
  121 Safety Committee 10/10/13
  122 Tobacco Free Campus 10/10/13
  137 Visitors to the Facility 10/10/13
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200 Fiscal Property  
  201 Donated Funds 10/10/13
  202 Supply Order From (All Departments except Food Service 10/10/13
  202 Attachment 1 Supply Order From 10/10/13
  203 Purchasing Procedures 10/10/13
  203 Attachment 1 Requisition 04/14/11
  204 Disposition of State Property 10/10/13
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300 Business Office  
  302 Resident Checking / Bank Statement Reconciliation 01/09/14
  303 Contingent Revolving Account / Bank Statement Reconciliation 01/09/14
  304 Stale Dated Checks 01/09/14
  305 Resident Accounts Cash Box 01/09/14
  305 Attachment 1 Daily Cash Box Reconciliation 01/09/14
  305 Attachment 2 Monthly Cash Box Reconciliation 01/09/14
  306 Resident Trust Funds Month End Balance Report 01/09/14
  307 Signatures on Accounts Payable Vouchers 01/09/14
  307 Attachment 1 Accounts Payable Voucher 01/09/14
  308 Resident Estates 01/09/14
  309 Receipt & Deposit of Resident Account Checks 04/14/11
  310 Resident Account Purchases 01/09/14
  310 Attachment 1 Resident Account Voucher 01/09/14
  311 Resident Mail Orders 01/09/14
  312 Resident Funds Deposits & Withdrawals 01/09/14
  312 Attachment 1 Resident Accounts Withdrawal Certificate 01/09/14
  314 Resident Funds Held in Trust 01/09/14
  315 Copy Machine 01/09/14
  315 Attachment 1 DPHHS Copying Cost Policy 01/09/14
  316 Resident Hair Care Services 01/09/14
  316 Attachment 1 Resident Hair Care Voucher 01/09/14
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400 Personnel  
  401 Sick Leave Policy - Department of Administration 01/09/14
  401 Attachment 1 Sick Leave Policy - Montana Mental Health Nursing Care Center 01/09/14
  401 Attachment 2 Request For Leave of Absence 01/09/14
  402 Sick Leave usage for Intermittent Employees 01/09/14
  403 Annual Vacation Leave Usage 01/09/14
  403 Attachment 1 Annual Vacation Leave Usage - Department of Administration 01/09/14
  404 Use of Earned Holiday Time 01/09/14
  Request For Leave of Absence 01/09/14
  404 Attachment 2 Holidays 01/09/14
  405 Employee Request Form 01/09/14
  Request For Leave of Absence 01/09/14
  406 Cancellation of Scheduled Annual Leave, Holiday Leave & Leave without Pay 01/09/14
  407 Inservice 01/09/14
  408 Leave of Absence without Pay 01/09/14
  408 Attachment 1 Human Resource Policy #230 01/09/14
  409 Tardy or Absent from Work 01/09/14
  410 Hiring of Employees 01/09/14
  410 Attachment 1 Score Sheet 01/09/14
  410 Attachment 2 Human Resource Policy #115 01/09/14
  411 Letters of Hire and Denial 01/09/14
  412 Affirmative Action / Equal Employment Opportunity Policy 01/09/14
  412 Attachment 1 Nondiscrimination-EEO 01/09/14
  412 Attachment 2   01/09/14
  412 Attachment 2a   01/09/14
  412 Attachment 3   01/09/14
  413 Work Related Injury 01/09/14
  413 Attachment 1 Telephone Reporting Worksheet 01/09/14
  414 Employee Dress and Grooming 01/09/14
  415 Employee Evaluations 01/09/14
  415 Attachment 1 Performance Management and Evaluation 01/09/14
  415 Attachment 2 Employee Performance Evaluation 01/09/14
  416 Employee’s Personnel File Information 01/09/14
  417 Use of Alcohol Beverages and non-Prescribed Conscious Altering Drugs 01/09/14
  417 Attachment 1 Human Resource Policy #160 01/09/14
  418 Time Clock Usage 01/09/14
  419 Investigations 01/09/14
  419 Attachment 1 Human Resource Guide #220 01/09/14
  420 Rest Break Areas 01/09/14
  420 Attachment 1 Indoor / Outdoor Break Areas Map 01/09/14
  421 Employee Conduct 01/09/14
  421 Attachment 1 Guidelines for Employee Conduct 01/09/14
  422 New Employee Orientation 01/09/14
  422 Attachment 1 New Employee Orientation Checklist 01/09/14
  423 Worker’s Compensation 01/09/14
  423 Attachment 1 Human Resource Policy #340 01/09/14
  424 Employee Communication 01/09/14
  427 Employee Sick Leave Call-In 01/09/14
  428 Leave Requests 01/09/14
  428 - Attachment 1 Request For Leave of Absence 01/09/14
  429 Non-Union Grievance 01/09/14
  429 Attachment 1 Grievance Policy - Administrative Rules of the State of Montana (ARM) 01/09/14/td>
  430 Employee Telephone Usage 01/09/14
  431 Thanksgiving, Christmas and New Year’s Holiday Scheduling 01/09/14
  432 Employee Mail 01/09/14
  432 Attachment 1 Procedures For Handling Suspicous Envelopes Or Packages 01/09/14
  433 Employee Montana Operator’s Drivers License 01/09/14
  434 Employee Identification Tags 01/09/14
  435 Employee Rest Breaks & Meal Periods 01/09/14
  436 Early Return to Work 01/09/14
  436 Attachment 1 Return to Work Recommendations 01/09/14
  436 Attachment 2 ERTW Letter from Employer to Injured Employee 01/09/14
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500 Nursing  
  501 Fall Risk Policy 10/27/11
  501 Attachment 1 Fall Risk Assesment  
  502 Resident Accident Incident Reporting 10/27/11
  502 Attachment 1 Accident or Incident Report  
  503 Short Wave Radios 10/27/11
  504 Registered Nurses Licenses 10/27/11
  506 MANDT Hold &/or Involuntary Administration of IM Medication 10/27/11
  506 Attachment 1 MANDT Hold &/or Involuntary Administration of IM Medication Form  
  509 Rehabilitative Services 10/27/11
  509 Attachment 1 Policy #0509 Attachment #1  
  509 Attachment 2 Consultant Report  
  510 Certified Nursing Assistants Assigned Work Areas 10/27/11
  513 Use of Grand Master Key 10/27/11
  515 Continuing Education 10/27/11
  517 Safe Medical Devices Act 01/12/12
  519 Secure Wing / E-1 Wing 01/12/12
  520 Admitting Residents to Secure Unit / E-1 01/12/12
  520 Attachment 1 Selection Criteria for residents on F-Wing  
  522 Admissions Criteria to E-2 Wing 01/12/12
  522 Attachment 1 Selection Criteria for residents on E-Wing  
  523 Assistive Restraints – Safety Device or Restraint 01/29/14
  523 Attachment 1 Restraint Authorization 01/29/14
  523 Attachment 2 Family/Guardian  
  523 Attachment 3 Restraint Identification  
  523 Attachment 4 Use Of Safety Devices And Restraint  
  524 Resident Transportation 01/12/12
  524 Attachment 1 Travel Log  
  525 Admissions Procedure 01/12/12
  525 Attachment 1 Inventory of Personal Effects on Admission/Discharge  
  525 Attachment 2 Valuables Envelope  
  525 Attachment 3 Nursing Physical Assessment  
  525 Attachment 4 Braden Scale  
  525 Attachment 5 Pain Assessment  
  525 Attachment 6 Pain Flow Sheet  
  525 Attachment 7 Initial Care Plan  
  526 Quality Assurance 01/12/12
  527 Prophylaxis Against Tetanus and Diphtheria 07/11/13
  528 Secure Care system 07/11/13
  528 Attachment 1 Check List for Secure Care Alarms  
  529 Care Planning 01/12/12
  530 Resident Death 01/12/12
  530 Attachment 1 Contract Attorney 07/11/13
  530 Attachment 2 Inventory of Personal Effects on Admission/Discharge  
  530 Attachment 3 Resident Death Report  
  530 Attachment 4 Authorization for Removal of Deceased Resident  
  530 Attachment 5 Funeral Plans Questionnaire  
  530 Attachment 6 Vital Statistics for Funeral Homes  
  533 Resident Bathing Procedure 01/12/12
  534 Involuntary Medications 01/12/12
  534 Attachment 1 Involuntary Medication Review Committee  
  535 Electronic Signatures 07/14/11
  536 Abnormal Involuntary Movement Scale ExaminTION 01/12/12
  536 Attachment 1 Examination Proceddure  
  539 Recording Intake and Output 01/12/12
  541 Neuro Assessment 01/12/12
  541 Attachment 1 Vital Statistics  
  542 Oxygen Therapy 01/12/12
  543 Oxygen, Equipment, Nebulizers, and Equipment Utilization 01/12/12
  544 Cleaning of Oxygen Concentrator 01/12/12
  545 Paraffin Bath 01/12/12
  546 Pressure Ulcers: Prediction and Prevention 01/12/12
  546 Attachment 1 Braden Scale  
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600 Infection Control  
  601 Cleaning & Decontaminating Body Fluid Spills 10/21/92
  602 Control of Communicable & Infectious Diseases 05/16/83
  603 Infection Control Committee 07/11/13
  604 Tuberculin Detection, Prevention & Control Policy 07/11/13
  604 Attachment 1 Consent for PPD 07/11/13
  604 Attachment 2 Certification from Active Tuberculosis 07/11/13
  604 Attachment 3 TB Screening Questionnaire 07/11/13
  605 Central Venous Catheter Care 09/12/94
  608 Management of Infected Health Care Workers with Hepatitis B Virus, HIV and/or AIDS 10/21/92
  612 Residents with Tuberculosis 04/19/94
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700 Food Service  
  701 Meal Serving Plan

02/21/13

  702 Scope of the Food Service Department 05/16/83
  703 Dietary Department Interdepartmental Communications and Relations 05/16/83
  704 New Admissions and Diet Changes 10/27/11
  704 Attachment 1 Liberalized Diet Plan  
  705 Change of Residents Seating Location 10/27/11
  706 Diet Manual 10/27/11
  707 Nourishments 05/16/83
  708 Employee Meal Service 09/12/84
  709 Visitor’s Meals 09/12/84
  710 Hair Restraints 02/11/11
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800 Maintenance  
  801 Energy Conservation 01/21/92
  802 Fire Protection System, Equipment & Training Employees 05/16/83
  803 Maintenance Work Request Form 05/16/83
  803 Attachment 1 Maintenance Department Work Request  
  804 Emergency Shut-0ffs for Main Gas Line, Main Electrical Power, Main Water Supply, Main Fire Sprinkling System 05/16/83
  805 Traffic Control 05/16/83
  806 State Vehicles 05/16/83
  806 Attachment 1 Parking Map  
  807 Boiler Observation Check 02/01/94
  808 After Hour Maintenance Emergencies 05/16/03
  809 Key Policy 05/16/83
  810 Affixing Items to Interior Walls, Ceilings, Doors and Floors 05/16/83
  811 Relocation and Installing of Appliances & Equipment 05/16/83
  812 Fire Watch 02/13/12
  813 Fire Plan 05/16/83
  813 Attachment 1 Fire Report Form  
  813 Attachment 2 Fire Drill Report 02/19/08
  813 Attachment 3 Information About The Fire Alarm System  
  814 Environmental / Safety Inspection Team 01/24/85
  815 Employee Vehicle Policy 01/24/85
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900 Laundry  
  901 Laundry Services 07/11/13
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1000 Housekeeping  
  1001 Sanitation 10/11/95
  1002 Floor Resurfacing 10/11/95
  1003 Pest Control 05/16/83
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1100 Clinical Support  
  1101 Scope of Social Services 09/09/13
  1102 Resident Social History Evaluation / Progress Notes 09/09/13
  1102 Attachment 1 Social History/Assessment 09/09/13
  1102 Attachment 2 Social/Emotional Assessment 09/09/13
  1103 Resident’s Rights 09/09/13
  1103 Attachment 1 Page 1 Resident’s Rights and Responsibilities 09/09/13
  1103 Attachment 1 Page 2 Resident’s Rights and Responsibilities 09/09/13
  1103 Attachment 2 Family Information Form Attachment 09/09/13
  1104 Abuse, Exploitation, Mistreatment and / or Neglect of Residents 09/09/13
  1104 Attachment 1 Resident Abuse/Neglect/Misappropriation Reporting Form 09/09/13
  1105 Resident Rights Grievance Procedure 09/09/13
  1105 Attachment 1 Resident Rights Grievance Report Form 09/09/13
  1106 Residents Lost or Stolen Items Procedure 09/09/13
  1107 Resident Mail 09/09/13
  1107 Attachment 1 Personal Finance Permission 09/09/13
  1107 Attachment 2 Representative Payee Procedure - Financial Statement 09/09/13
  1108 Residents Use of the Telephone 09/09/13
  1109 Photographs 09/09/13
  1109 Attachment 1 Release for Photograph 09/09/13
  1110 Pet Protocol 09/09/13
  1112 Resident Off-Campus Release 09/09/13
  1112 Attachment 1 Off-Campus Release Agreement 09/09/13
  1113 Resident Sharp Object Possession 09/09/13
  1114 Resident Referral Process 09/09/13
  1114 Attachment 1 Information Admission by Involuntary Commitment 09/09/13
  1114 Attachment 1a Application for Admission by Involuntary Commitment 09/09/13
  1114 Attachment 2 Information Voluntary Admission 09/09/13
  1114 Attachment 2a Application for Voluntary Admission 09/09/13
  1115 Advance Medical Directive 09/09/13
  1115 Attachment 1 Instructions for Healthcare (Living Will) 09/09/13
  1116 Facility Initiated Discharge Protocol 09/09/13
  1116 Attachment 1 Care Plan Team 09/09/13
  1116 Attachment 2 Notice Of Transfer Or Discharge 09/09/13
  1116 Attachment 3 Resident Letter 09/09/13
  1116 Attachment 4 Aftercare Plan 09/09/13
  1116 Attachment 5 Discharge Letter 09/09/13
  1116 Attachment 6 Information for Business Office on Resident Transfers 09/09/13
  1117 Donation Receipt 09/09/13
  1118 Resident Admissions & Orientation 09/09/13
  1118 Attachment 1 Funeral Plans Questionnaire 09/09/13
  1118 Attachment 2 Family information 09/09/13
  1118 Attachment 3 MDS Letter 09/09/13
  1118 Attachment 4 Abuse Education Letter 09/09/13
  1118 Attachment 5 Consent Routine Proc 09/09/13
  1118 Attachment 6 Consent Authorization Letter 09/09/13
  1118 Attachment 7 Authorization to Consent to Treatment of Incompetent Patient 09/09/13
  1118 Attachment 7a Authorization to Consent to Treatment 09/09/13
  1118 Attachment 8 HIPPA Information 09/09/13
  1118 Attachment 9 Privacy Form 09/09/13
  1118 Attachment 10 Auth Share Prot Health 09/09/13
  1118 Attachment 10a Auth Share Prot Health 09/09/13
  1119 Resident Guardianships 09/09/13
  1119 Attachment 1 Guardianship Recommendation 09/09/13
  1120 Bed Hold Policy 09/09/13
  1120 Attachment 1 Bed Hold Policy 09/09/13
  1120 Attachment 2 Bed Hold Payments 09/09/13
  1121 Notice of Resident Discharge or Transfer 09/09/13
  1122 Discharge Planning 09/09/13
  1122 Attachment 1 Discharge Planning Care Plam Team 09/09/13
  1122 Attachment 2 Notice of Transfer or Discharge 09/09/13
  1122 Attachment 3 Aftercare Plan 09/09/13
  1122 Attachment 4 Aftercare Plan Letter 09/09/13
  1122 Attachment 5 Request for Discharge Against Medical Advice 09/09/13
  1122 Attachment 6 Information for Business Office on Resident Transfers 09/09/13
  1124 Accommodating Patients’ Special Education Needs 09/09/13
  1125 Resident Work Plan 09/09/13
  1126 Resident Work Program/Performance Evaluations 09/09/13
  1126 Attachment 1 Performance Evaluation 09/09/13
  1126 Attachment 2 Resident Assessment for Determination for Rate of Pay 09/09/13
  1126 Attachment 3 Determination for Rate of Pay 09/09/13
  1127 Resident Work Program Payroll 09/09/13
  1127 Attachment 1 Employee Time and Attendance Report 09/09/13
  1128 Recruitment/Selection of Resident Workers 09/09/13
  1128 Attachment 1 Resident Work ProgramPayroll Notification Form 09/09/13
  1129 Resident Work Program Dismissal 09/09/13
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1200 Recreation  
  1201 Mission and Purposes of the Department 04/11/13
  1202 Resident Recreational Outings 04/11/13
  1202 Attachment 1 Resident Recreation Event 04/11/13
  1203 Faith and Cultural Services 04/11/13
  1204 Volunteer Services 04/11/13
  1205 Recreation Program Documentation 04/11/13
  1205 Attachment 1 Recreation Assessment 04/11/13
  1205 Attachment 2 Recreation Participation Record 04/11/13
  1205 Attachment 3 Recreation Observation 04/11/13
  1206 Activities Program 04/11/13
  1207 Protective Wing Psychosocial Needs 04/11/13
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1400 Medical Records  
  1401 Medical Records Admission 07/11/13
  1401 Attachment 1 Immunization & PPD Schedule 07/11/13
  1402 Discharge Planning 10/09/08
  1402 Attachment 1 Resident Letter  
  1402 Attachment 2 Notice Of Transfer Or Discharge  
  1402 Attachment 3 Aftercare Plan  
  1402 Attachment 4 Resident Letter  
  1402 Attachment 5 Request for Discharge Against Medical Advice  
  1402 Attachment 6 Information for Business Office on Resident Transfers  
  1403 Arrangement of Medical Record Chart at the Nursing Stations 07/11/13
  1407 Confidentiality of Resident Information 07/11/13
  1407 Attachment 1 Authorization for Release of Information 07/11/13
  1408 HIPAA Privacy Policy 07/11/13
  1408 Attachment 1 Support Services 07/11/13
  1409 Daily Census Report 07/11/13
  1409 Attachment 1 Daily Census Report 07/11/13
  1416 Monthly Census Statistical Report 07/11/13
  1416 Attachment 1 Monthly Report 07/11/13
  1416 Attachment 1a Annual Report 07/11/13
  1416 Attachment 1b Report 07/11/13
  1417 Patients Daily Census 10/21/10
  1417 Attachment 1 Patients Daily Census Form  
  1419 Verbal Orders from Physician 07/11/13
  1419 Attachment 1 Physician's Telephone Orders 07/11/13
  1420 Admission and Discharge Register 07/11/13
  1422 Auditing and Purging of Medical Records 07/11/13
  1423 Resident Record Retention / Retrieval 07/11/13
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1500 Exposure Control Plan  
  1500 Universal Precautions / Standard Precautions 07/11/13
  1501 Safety Devices 07/11/13
  1502 Hand Devices 07/11/13
  1503 Handling and Disposal of Needles and Sharps 07/11/13
  1504 Ingestion of Blood Borne Pathogens 07/11/13
  1505 Handling of Potentially Infections Specimens 07/11/13
  1506 Personal Protective Equipment (PPE) 07/11/13
  1507 Cleaning Potentially Contaminated Equipment & Work Areas 07/11/13
  1508 Infections / Biohazard Waste 07/11/13
  1509 Laundry Handling Practices 07/11/13
  1510 Blood Borne Diseases and Health Care Workers 07/11/13
  1511 Hepatitis B Vaccination 07/11/13
  1511 Attachment 1 Consent Form 07/11/13
  1511 Attachment 2 Declination Form 07/11/13
  1511 Attachment 3 Revaccination Notice 07/11/13
  1512 Exposure Incident Evaluation and Follow-Up 07/11/13
  1512 Attachment 1 Exposure Incident Report 07/11/13
  1512 Attachment 2 Post Exposure Evaluator Written Opinion 07/11/13
  1512 Attachment 3 Employee Exposure to Blood and Body Fluids 07/11/13
  1512 Attachment 4 Post Exposure Medical Evaluation Form 07/11/13
  1512 Attachment 5

 Employee Exposure To Blood And Body Fluids Form

07/11/13
  1513 Labeling of Potentially Hazardous Material 07/11/13
  1515 Occupational Exposure Training 07/11/13
  1516 Employee Medical Records 07/11/13
  1516 Attachment 1 Employee Medical Record 07/11/13
  1516 Attachment 2 Post-Exposure Follow-Up 07/11/13
  1516 Attachment 3 Post-Exposure Follow-Up 07/11/13
  1516 Attachment 4 Post-Exposure Follow-Up Potentially Infectious Material 07/11/13
  1516 Attachment 5 Hiv/Aids Virus Antibody Blood Test Consent Form 07/11/13
  1516 Attachment 5a Hepatitis B Virus And Hepatitis C Virus Blood Test 07/11/13
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1600 Pharmacy  
  1600 Access to Pharmacy 01/28/11
  1601 Handling of Hazardous / Chemotherapeutic Drugs 01/28/11
  1602 Dealing with Licensing Agencies 01/28/11
  1603 Unit Dose Drug Distribution System 01/28/11
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Page last updated: 04/01/2014