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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  
  Mission Statement 04/14/11
  Organizational Chart 04/14/11
  Policy Procedure 04/14/11
  Communication with News Media 04/14/11
  Superintendent Absence 02/21/13
  Solicitation 04/14/11
  Elopement Risk 04/14/11
  Missing Persons 04/14/11
  Response to Violent Crime or Suicide 04/14/11
  Resident / Employee Transactions 04/14/11
  Resident  /Employee Transaction Form 04/14/11
  Sexual Harassment 04/14/11
  119 Attachment 1 Equal Employment Oppertunity, Non-Discrimination and Harrassment Prevention 11/14/08
  Emergency Plan 12/23/12
  Emergency Telephone Numbers 12/23/12
  120 Attachment 1a Emergency Telephone Numbers 12/23/12
  General Orientation to Organization 12/23/12
  Facility Map 12/23/12
  Water Service 04/14/11
  120 Attachment 5 Strike Contingency Plan 12/23/12
  Safety Committee 04/14/11
  Tobacco Free Campus 04/14/11
  Visitors to the Facility 04/14/11
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200 Fiscal Property  
  Donated Funds 04/14/11
  Supply Order From (All Departments except Food Service 04/14/11
  Supply Order From 04/14/11
  Purchasing Procedures 04/14/11
  Requisition 04/14/11
  Disposition of State Property 04/14/11
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300 Business Office  
  Resident Checking / Bank Statement Reconciliation 04/14/11
  Contingent Revolving Account / Bank Statement Reconciliation 04/14/11
  Stale Dated Checks 04/14/11
  Resident Accounts Cash Box 04/14/11
  Daily Cash Box Reconciliation 04/14/11
  Monthly Cash Box Reconciliation 04/14/11
  Resident Trust Funds Month End Balance Report 04/14/11
  Signatures on Accounts Payable Vouchers 04/14/11
  Accounts Payable Voucher 04/14/11
  Resident Estates 04/14/11
  Receipt & Deposit of Resident Account Checks 04/14/11
  Resident Account Purchases 04/14/11
  Resident Account Voucher 04/14/11
  Resident Mail Orders 04/14/11
  Resident Funds Deposits & Withdrawals 04/14/11
  Resident Funds Held in Trust 04/14/11
  Copy Machine 04/14/11
  DPHHS Copying Cost Policy 04/14/11
  Resident Hair Care Services 04/14/11
  Resident Hair Care Voucher 04/14/11
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400 Personnel  
  Sick Leave Policy - Department of Administration 03/24/11
  Sick Leave Policy - Montana Mental Health Nursing Care Center 07/14/11
  Request For Leave of Absence 07/01/91
  Sick Leave usage for Intermittent Employees 07/14/11
  Annual Vacation Leave Usage 07/14/11
  Annual Vacation Leave Usage - Department of Administration 03/18/11
  Use of Earned Holiday Time 07/14/11
 
Request For Leave of Absence 07/01/91
  Holidays 06/02/97
  Employee Request Form 07/14/11
 
Request For Leave of Absence 07/01/91
  Cancellation of Scheduled Annual Leave, Holiday Leave & Leave without Pay 07/14/11
  Inservice 07/14/11
  Leave of Absence without Pay 07/14/11
  Human Resource Policy #230 12/99
  Tardy or Absent from Work 07/14/11
  Hiring of Employees 07/14/11
  Score Sheet  
  Human Resource Policy #115  
  Letters of Hire and Denial 07/14/11
  Affirmative Action / Equal Employment Opportunity Policy 07/14/11
  Nondiscrimination-EEO 12/22/00
  Work Related Injury 07/14/11
  Telephone Reporting Worksheet  
  Employee Dress and Grooming 07/14/11
  Employee Evaluations 07/14/11
  Performance Management and Evaluation 08/28/98
  Employee Performance Evaluation  
  Employee’s Personnel File Information 07/14/11
  Use of Alcohol Beverages and non-Prescribed Conscious Altering Drugs 07/14/11
  Human Resource Policy #160  
  Time Clock Usage 07/14/11
  Investigations 07/14/11
  Human Resource Guide #220  
  Rest Break Areas 07/14/11
  Indoor / Outdoor Break Areas Map  
  New Employee Orientation 07/14/11
  New Employee Orientation Checklist  
  Worker’s Compensation 10/27/11
  Human Resource Policy #340 07/01/03
  Employee Communication 10/27/11
  Drug-Free Workplace Policy 10/27/11
  Human Resource Policy #160 04/96
  Employee Sick Leave Call-In 10/27/11
  Leave Requests 10/27/11
  Request For Leave of Absence 07/01/91
  Non-Union Grievance 10/27/11
  Grievance Policy - Administrative Rules of the State of Montana (ARM)  
  Employee Telephone Usage 10/27/11
  Thanksgiving, Christmas and New Year’s Holiday Scheduling 10/27/11
  Employee Mail 10/27/11
  Procedures For Handling Suspicous Envelopes Or Packages 10/27/11
  Employee Montana Operator’s Drivers License 10/27/11
  Employee Identification Tags 10/27/11
  Employee Rest Breaks & Meal Periods 10/27/11
  Early Return to Work 10/27/11
  Return to Work Recommendations  
  ERTW Letter from Employer to Injured Employee  
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500 Nursing  
  Fall Risk Policy 10/27/11
  Fall Risk Assesment  
  Resident Accident Incident Reporting 10/27/11
  Accident or Incident Report  
  Short Wave Radios 10/27/11
  Registered Nurses Licenses 10/27/11
  MANDT Hold &/or Involuntary Administration of IM Medication 10/27/11
  MANDT Hold &/or Involuntary Administration of IM Medication Form  
  Rehabilitative Services 10/27/11
  Policy #0509 Attachment #1  
  Consultant Report  
  Certified Nursing Assistants Assigned Work Areas 10/27/11
  Use of Grand Master Key 10/27/11
  Continuing Education 10/27/11
  Safe Medical Devices Act 01/12/12
  Secure Wing / E-1 Wing 01/12/12
  Admitting Residents to Secure Unit / E-1 01/12/12
  Selection Criteria for residents on F-Wing  
  Admissions Criteria to E-2 Wing 01/12/12
  Selection Criteria for residents on E-Wing  
  Assistive Restraints – Safety Device or Restraint 01/12/12
  Restraint Authorization  
  Family/Guardian  
  Restraint Identification  
  Use Of Safety Devices And Restraint  
  Resident Transportation 01/12/12
  Travel Log  
  Admissions Procedure 01/12/12
  Inventory of Personal Effects on Admission/Discharge  
  Valuables Envelope  
  Nursing Physical Assessment  
  Braden Scale  
  Pain Assessment  
  Pain Flow Sheet  
  Initial Care Plan  
  Quality Assurance 01/12/12
  Prophylaxis Against Tetanus and Diphtheria 07/14/11
  Secure Care system  
  Check List for Secure Care Alarms  
  Care Planning 01/12/12
  Resident Death 01/12/12
  Contract Attorney  
  Inventory of Personal Effects on Admission/Discharge  
  Resident Death Report  
  Authorization for Removal of Deceased Resident  
  Funeral Plans Questionnaire  
  Vital Statistics for Funeral Homes  
  Resident Bathing Procedure 01/12/12
  Involuntary Medications 01/12/12
  Involuntary Medication Review Committee  
  Electronic Signatures 07/14/11
  Abnormal Involuntary Movement Scale ExaminTION 01/12/12
  Examination Proceddure  
  Recording Intake and Output 01/12/12
  Neuro Assessment 01/12/12
  Vital Statistics  
  Oxygen Therapy 01/12/12
  Oxygen, Equipment, Nebulizers, and Equipment Utilization 01/12/12
  Cleaning of Oxygen Concentrator 01/12/12
  Paraffin Bath 01/12/12
  Pressure Ulcers: Prediction and Prevention 01/12/12
  Braden Scale  
Top
 
600 Infection Control  
  Cleaning & Decontaminating Body Fluid Spills 10/21/92
  Control of Communicable & Infectious Diseases 05/16/83
  Infection Control Committee 05/16/83
  Tuberculin Detection, Prevention & Control Policy 04/18/94
  Consent for PPD  
  Certification from Active Tuberculosis  
  TB Screening Questionnaire  
  Central Venous Catheter Care 09/12/94
  Management of Infected Health Care Workers with Hepatitis B Virus, HIV and/or AIDS 10/21/92
  Residents with Tuberculosis 04/19/94
Top
 
700 Food Service  
  Meal Serving Plan

02/21/13
  Scope of the Food Service Department 05/16/83
  Dietary Department Interdepartmental Communications and Relations 05/16/83
  New Admissions and Diet Changes 10/27/11
  Liberalized Diet Plan  
  Change of Residents Seating Location 10/27/11
  Diet Manual 10/27/11
  Nourishments 05/16/83
  Employee Meal Service 09/12/84
  Visitor’s Meals 09/12/84
  Hair Restraints 02/11/11
Top
800 Maintenance  
  Energy Conservation 01/21/92
  Fire Protection System, Equipment & Training Employees 05/16/83
  Maintenance Work Request Form 05/16/83
  Maintenance Department Work Request  
  Emergency Shut-0ffs for Main Gas Line, Main Electrical Power, Main Water Supply, Main Fire Sprinkling System 05/16/83
  Traffic Control 05/16/83
  State Vehicles 05/16/83
  Parking Map  
  Boiler Observation Check 02/01/94
  After Hour Maintenance Emergencies 05/16/03
  Key Policy 05/16/83
  Affixing Items to Interior Walls, Ceilings, Doors and Floors 05/16/83
  Relocation and Installing of Appliances & Equipment 05/16/83
  Fire Watch 02/13/12
  Fire Plan 05/16/83
  Fire Report Form  
  Fire Drill Report 02/19/08
  Information About The Fire Alarm System  
  Environmental / Safety Inspection Team 01/24/85
  Employee Vehicle Policy 01/24/85
Top
 
900 Laundry  
  901 Laundry Services 01/10/13
Top
 
1000 Housekeeping  
  Sanitation 10/11/95
  Floor Resurfacing 10/11/95
  Pest Control 05/16/83
Top
 
1100 Clinical Support  
  Scope of Social Services 02/21/13
  Resident Social History Evaluation / Progress Notes 02/21/13
  Social History/Assessment 02/21/13
  Social/Emotional Assessment 02/21/13
  Resident’s Rights 02/21/13
  Resident’s Rights and Responsibilities 02/21/13
  Resident’s Rights and Responsibilities 02/21/13
  Family Information Form Attachment 02/21/13
  Abuse, Exploitation, Mistreatment and / or Neglect of Residents 02/21/13
  Resident Abuse/Neglect/Misappropriation Reporting Form 02/21/13
  Resident Rights Grievance Procedure 02/21/13
  Resident Rights Grievance Report Form 02/21/13
  Residents Lost or Stolen Items Procedure 02/21/13
  Resident Mail 02/21/13
  Personal Finance Permission 02/21/13
  Representative Payee Procedure - Financial Statement 02/21/13
  Residents Use of the Telephone 02/21/13
  Photographs 02/21/13
  Release for Photograph 02/21/13
  Pet Protocol 02/21/13
  Resident Off-Campus Release 02/21/13
  Off-Campus Release Agreement 02/21/13
  Resident Sharp Object Possession 02/21/13
  Resident Referral Process 02/21/13
  Information Admission by Involuntary Commitment 02/21/13
  Application for Admission by Involuntary Commitment 02/21/13
  Information Voluntary Admission 02/21/13
  Application for Voluntary Admission 02/21/13
  Advance Medical Directive 02/21/13
  Instructions for Healthcare (Living Will) 02/21/13
  Facility Initiated Discharge Protocol 02/21/13
  Care Plan Team 02/21/13
  Notice Of Transfer Or Discharge 02/21/13
  Resident Letter 02/21/13
  Aftercare Plan 02/21/13
  Discharge Letter 02/21/13
  1116 Attachment 6 Information for Business Office on Resident Transfers 02/21/13
  Donation Receipt 02/21/13
  Resident Admissions & Orientation 02/21/13
  Funeral Plans Questionnaire 02/21/13
  Family information 02/21/13
  MDS Letter 02/21/13
  Abuse Education Letter 02/21/13
  Consent Routine Proc 02/21/13
  Consent Authorization Letter 02/21/13
  Authorization to Consent to Treatment of Incompetent Patient 02/21/13
  1118 Attachment 7a Authorization to Consent to Treatment 02/21/13
  HIPPA Information 02/21/13
  Privacy Form 02/21/13
  Auth Share Prot Health 02/21/13
  1118 Attachment 10a Auth Share Prot Health 02/21/13
  Resident Guardianships 02/21/13
  Guardianship Recommendation 02/21/13
  Bed Hold Policy 02/21/13
  Bed Hold Policy 02/21/13
  Bed Hold Payments 02/21/13
  Notice of Resident Discharge or Transfer 02/21/13
  1122 Discharge Planning 02/21/13
  1122-1 Discharge Planning Care Plam Team 02/21/13
  1122-2 Notice of Transfer or Discharge 02/21/13
  1122-3 Aftercare Plan 02/21/13
  1122-4 Aftercare Plan Letter 02/21/13
  1122-5 Request for Discharge Against Medical Advice 02/21/13
  1122-6 Information for Business Office on Resident Transfers 02/21/13
  Accommodating Patients’ Special Education Needs 02/21/13
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1200 Recreation  
  1201 Mission and Purposes of the Department 04/11/13
  Resident Recreational Outings 04/11/13
  Resident Recreation Event 04/11/13
  Faith and Cultural Services 04/11/13
  Volunteer Services 04/11/13
  Recreation Program Documentation 04/11/13
  Recreation Assessment 04/11/13
  Recreation Participation Record 04/11/13
  Recreation Observation 04/11/13
  Activities Program 04/11/13
  Protective Wing Psychosocial Needs 04/11/13
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1300 Resident Work Program  
  Resident Work Program 04/11/13
  Resident Work Program / Performance Evaluations 04/11/13
  Performance Evaluation 04/11/13
  Resident Assessment for Determination for Rate of Pay 04/11/13
  Determination for Rate of Pay 04/11/13
  Resident Work Program / Payroll 04/11/13
  Employee Time and Attendance Report 04/11/13
  Recruitment / Selection of Resident Workers 04/11/13
  Payroll Notification Form 04/11/13
  Resident Work Program Dismissal 04/11/13
Top
 
1400 Medical Records  
  Medical Records Admission 10/21/10
  Immunization & PPD Schedule  
  Discharge Planning 10/09/08
  Resident Letter  
  Notice Of Transfer Or Discharge  
  Aftercare Plan  
  Resident Letter  
  Request for Discharge Against Medical Advice  
  Information for Business Office on Resident Transfers  
  Arrangement of Medical Record Chart at the Nursing Stations 10/21/10
  Confidentiality of Resident Information 10/21/10
  Authorization for Release of Information  
  HIPAA Privacy Policy 10/21/12
  Support Seervices  
  Daily Census Report 10/09/08
  Daily Census Report  
  Monthly Census Statistical Report 10/21/10
  Monthly Report  
  Annual Report  
  Patients Daily Census 10/21/10
  Patients Daily Census Form  
  Verbal Orders from Physician 10/21/10
  Physician's Telephone Orders  
  Admission and Discharge Register 10/21/10
  Auditing and Purging of Medical Records 10/21/10
  Resident Record Retention / Retrieval 10/21/10
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1500 Exposure Control Plan  
  Universal Precautions / Standard Precautions 01/28/11
  Safety Devices 01/28/11
  Hand Devices 01/28/11
  Handling and Disposal of Needles and Sharps 01/08/11
  Ingestion of Blood Borne Pathogens 01/28/09
  Handling of Potentially Infections Specimens 01/28/11
  personal Protective Equipment (PPE) 01/28/11
  Cleaning Potentially Contaminated Equipment & Work Areas 01/28/11
  Infections / Biohazard Waste 01/08/09
  Laundry Handling Practices 01/28/11
  Blood Borne Diseases and Health Care Workers 01/28/11
  Hepatitis B Vaccination 01/28/11
  Consent Form  
  Declination Form  
  Revaccination Notice  
  Exposure Incident Evaluation and Follow-Up 01/28/11
  Exposure Incident Report  
  Post Exposure Evaluator Written Opinion  
  Employee Exposure to Blood and Body Fluids  
  Occupational Exposure Training 01/28/11
  Employee Medical Records 01/28/11
  Employee Medical Record  
  Post-Exposure Follow-Up  
  Post-Exposure Follow-Up  
  Post-Exposure Follow-Up Potentially Infectious Material  
  Hiv/Aids Virus Antibody Blood Test Consent Form  
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1600 Pharmacy  
  Access to Pharmacy 01/28/11
  Handling of Hazardous / Chemotherapeutic Drugs 01/28/11
  Dealing with Licensing Agencies 01/28/11
  Unit Dose Drug Distribution System 01/28/11
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Page last updated: 04/19/2013