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Policy & Procedures

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TABLE OF CONTENTS

SECTION

TITLE/CONTENT

DATE ISSUED
OR REVISED

ORG 10 Index  
     

1

Organizational Overview (ORG)

 
ORG 01 Preface 01/00/2002
ORG 02 Organizational Chart 06/21/2013
ORG 03 Treatment Philosophy  
ORG 04 Guiding Principles & Working Guidelines 01/01/2002
ORG 05 Organizational Code of Ethics 01/01/2002
ORG 06 Ethics Committee 01/01/2002
ORG 07 Mission Statement 08/22/2012
ORG 08 Goals & Objectives 06/30/2013
ORG 09  Physical Plant Description 01/01/2002
ORG 10 Index 01/01/2002
ORG 11 Welcoming Policy 04/01/2009
     

2

Administrative Policies (ADP)

 
ADP 01 Americans with Disabilities Act (ADA) 03/10/2004
ADP 02 Visitors 01/01/2002
ADP 03 Food Service 01/01/2002
ADP 04 Tobacco Use 03/01/2011
ADP 05 Bargaining Units 03/28/2013
ADP 06 Vending Machines 02/14/2007
ADP 07 Office Machines 01/01/2002
ADP 08 Donations 10/08/2010
ADP 09 Supply Requests Forms 01/01/2002
ADP 10 Service Animals 01/01/2002
ADP 11 Weapons 01/01/2002
ADP 12 Contract Management 01/01/2002
ADP 13 Meal Sign In Log 07/05/2005
ADP 14 Legal Intervention on Patients 10/30/2003
ADP 15 Library Use Guidelines No Date
ADP 16 Tobacco Free Community Resinded
ADP 17 Policy Development, Revision, Approval , and Distribution 05/09/2013
ADP 18 Wall Hangings 09/30/2013
     

3

Personnel Policies (PRP)

 
PRP 01 Volunteer Workers 04/01/2009
PRP 02 Employee Conduct 01/01/2002
PRP 03 Compensatory Time & Overtime 01/01/2003
PRP 04 Personal Property in the Workplace 01/01/2002
PRP 05 Chemical Dependency Interns Rescinded
PRP 06 Licensed Addiction Counselor Trainee Rescinded
PRP 07 Sexual Harassment 04/04/2007
PRP 08 Licensure & Certification Requirements 10/01/2005
PRP 09 Recruitment & Hiring 07/05/2012
PRP 10 Dress Code 07/05/2012
PRP 11 Professional Legal Testimony 01/01/2002
PRP 12 Pay Plan 01/00/2002
PRP 13 New Employee Orientation 03/10/2010
PRP 14 Staff Training and Development 09/28/2012
PRP 15 Staffing Patterns 08/04/2010
PRP 16 Drug Free Workplace 01/20/2010
PRP 16(A) Drug Free Compliance Form 01/01/2002
PRP 17 Employee Performance Evaluations 01/01/2002
PRP 18 EEO & Non-Discrimination 01/01/2002
PRP 19  Leave Time 01/01/2002
PRP 20 Leave Requests 01/01/2002
PRP 21 Reporting Absence from Work 02/26/2010
PRP 22 Employee Resignation 01/01/2002
PRP 23 Disciplinary Action & Discharge Rescinded
  Grievance Procedure (Refer to M-O-M 3-0125, 6/2/97) MCDC Policy Rescinded
PRP 25 Selective Service Compliance 01/01/2002
PRP 26 Union Strike Plan 12/20/2012
PRP 27 Staffing Patterns Rescinded
PRP 28 Short Term Worker 09/28/2010
PRP 29 Employee Moving Expenses Rescinded
PRP 30 Salary and Wage Verification Policy 04/15/2013
PRP 31 Personal Cell Phone Use 04/01/2009
PRP 32 Staff communication plan 10/28/2009
PRP 33 Telephone Log 12/23/2009
PRP 34 On-Call Status Management 03/15/2010
PRP 35 Investigation Policy 10/20/2010
PRP 36

Fragrance In The Workplace

10/01/2012
     

5

Medical Records Policies (MRP)

 
MRP 01 Health Information Compliance 04/01/2007
MRP 02 Approved Medical Abbreviations 01/01/2002
MRP 03 Records Security 01/01/2002
MRP 04 Master Patient Index 01/01/2002
MRP 05 Totally Integrated Electronic Record (TIER) Not in Book
MRP 06  Forms Approval Process 01/01/2002
MPR 07 Documentation 01/01/2002
     

6

Clinical Treatment Policies (CTP)

 
CTP 01 Admission & Screening & Scheduling 09/30/2002
CTP 01A Admission of Montana State Hospital Patients 06/28/2006
CTP 02 Admissions Non-Discrimination 12/08/2009
CTP 03 Patient Consent for Treatment 01/01/2002
CTP 03 (A) Consent for Treatment 11/26/2002
CTP 04 Scope of Chemical Dependency Services 04/30/2012
CTP 05 Scope of Mental Health Services 01/18/2005
CTP 06 Hostile Patient Behavior 05/11/2011
CTP 07 Individual Treatment Plans 02/29/2012
CTP 08 Clinical Stay Review 05/04/2011
CTP 09 Length of Stay 12/13/2007
CTP 10 Patient Abuse 01/01/2002
CTP 11 Patient Bill of Rights  & Grievance 03/05/2005
CTP 11 (A) Patient Bill of Rights 04/01/2009
CTP 12  Patient Grievance Procedure 02/29/2012
CTP 13  Patient Grievance Committee - Recinded 05/09/2013
CTP 14 Belongings Search & Safekeeping Unauth. Items 05/09/2013
CTP 15 Safekeeping of Patient Valuables 06/30/2006
CTP 15a Safekeeping of Patient Money 02/14/2007
CTP 16 Mental Health Assessment/Screening 02/16/2012
CTP 17 Suicidal Patients 05/09/2011
CTP 18 Patient Emergency Leave 01/01/2002
CTP 19 Patient Therapeutic Leave from MSH Status  01/01/2002
CTP 20 Transfer to Montana State Hospital 03/15/2010
CTP 21 Patient Elopement 01/01/2002
CTP 22 Continued Care Planning 10/30/2003
CTP 23 Patient Discharge  06/24/2003
CTP 24 Mental Health Discharge Coordination  02/04/2005
CTP 25 Disciplinary Discharge  01/01/2002
CTP 26 Clinical Record Keeping  Fed. Reg. Vol. 40 – No 127   Part IV, 07195 02/14/2007
CTP 27 Inter-disciplinary Staffing 01/01/2002
CTP 28 Room Assignments 03/19/2003
CTP 29 Patient Monitoring 06/07/2005
CTP 30 Patient Belongings Received After Admission 01/05/2005
CTP 31 Patient Haircuts - Rescinded 08/01/2013
CTP 32 Parent Child Visitation 08/30/2005
CTP 33 Family Day 03/15/2010
CTP 34 Tape Player 06/28/2006
CTP 35 Therapeutic Guest Presentations 10/28/2009
CTP 36 Gifts to Patients 11/18/2009
CTP 37 Interdisciplinary Treatment Teams 01/11/2010
CTP 38 ASR discharges Policy 05/09/2001
CTP 39 Direct Patient Care Policy 02/23/2010
CTP 40 Child or Elder Abuse Policy 01/25/2012
CTP 41 Discharge Planning Policy 02/29/2012
CTP 42 Special Eudcation 04/09/2012
     

7

Infection Control Policies (ICP)

 
ICP 01 Employee Tuberculosis Screening 04/20/2012
ICP 02 Outline of exposure control Plan 11/10/2005
ICP 03 Hand Washing 01/10/2008
ICP 04 Clean up of Blood or OPIM 04/20/2011
ICP 05 Hepatitis B Vaccination 04/01/2007
ICP 06 Patient HIV Testing 12/23/2009
ICP 07 Protective Equipment Location 01/09/2008
ICP 08 Evaluation and Treatment of Pediculosis 01/01/2002
ICP 09 Occupational Exposure 03/02/2007
ICP 10 Infectious Control Guidelines 01/01/2002
ICP 11 Cleaning Supplies 01/01/2002
ICP 12 Patient Linen Exchange and Laundry Services 12/22/2010
ICP 13 Custodial  01/01/2002
ICP 14 Tuberculosis Screening Patients 01/01/2002
ICP 15 Autoclaving Stainless Steel Medical Equipment 01/01/2002
     

8

Medical & Nursing Policies (MNP)

 
MNP 01 Nursing Admission Process 01/12/2012
MNP 02 Admission of a Diabetic Patient 01/01/2002
MNP 03 Acutely Intoxicated Patient 01/01/2002
MNP 04 Change In Patient Status Form 01/01/2002
MNP 05 Seizures Protocol 01/01/2002
MNP 06 Anaphylactic Shock & Adrenalin Use 01/01/2002
MNP 07 Glucagon Emergency Kit 01/01/2002
MNP 08 Cardiopulmonary Resuscitation (CPR) 01/01/2002
MNP 09 Out Patient Medical Referral 01/01/2002
MNP 10 Medical Requests Xray, Emergency Surgical Need 01/01/2002
MNP 11 Dental Service 01/01/2002
MNP 12 Laboratory Specimen Collection 02/02/2011
MNP 13 Medication Administration 06/04/2012
MNP 13(A) Buprenorphine Administration - Rescinded 10/20/2005
MNP 14 Disposal of Patient Medication & Illegal Substances 02/25/2012
MNP 15 Use of Ambulance Service 01/01/2002
MNP 16 Unexpected Death  12/29/2011
MNP 17 Depo-Provera Injections 11/06/2008
MNP 18
Patient receipt of  personal medications
 
MNP 18 (A) Patient receipt of  personal medication 01/01/2002
MNP 19 Pregnant Patient 04/12/2012
MNP 20 Insomnia Protocol 02/19/2002
MNP 21 Medical Marijuana Policy 03/07/2005
MNP 22 Automated External Defibrillator 12/23/2009
MNP 23 Privacy and Separation by Gender 04/12/2012
MNP 24 Substance Abuse Testing Policy Cover Page 02/29/2012
     

9

Safety Policies (STP)

 
STP 01 Emergency Paging System Codes 01/09/2008
STP 02 Facility Security 06/30/2006
STP 03 Incident Reports  09/28/2012
STP 04 Employee Situation Reports 01/01/2002
STP 05 Building Maintenance 02/25/2012
STP 06 Disaster Response 11/29/2011
STP 07 Fire Emergency 01/01/2002
STP 08 Material Safety Data Sheets (MSDS) (Rescinded - Combined with Hazard Comm) Rescinded
STP 09 Hand Held Radios 01/01/2002
STP 10 Safety/Maintenance Inspections 12/15/2011
STP 11 Locking & Unlocking Doors 01/01/2002
STP 12 Explosions 03/06/2006
STP 13 Bomb Threat 03/06/2006
STP 14 Electrical  & Water Outage 03/06/2006
STP 15 Earthquake 03/06/2006
STP 16 High Winds 03/06/2006
STP 17 Thunderstorms 03/06/2006
STP 18 Early Return to Work 07/24/2008
STP 19 Patient Room Search 10/23/2003
STP 20 Proper Lifting Techniques 01/15/2005
STP 21 Inoperable Elevators 11/20/2003
STP 22 Hazard Communication Policy 01/06/2010
STP23 Program Closure/Treatment Cancellation 04/24/2012
     

10

Performance Improvement Policies (PIP)

 
PIP 01 Performance Improvement Committee  01/01/2002
PIP 02 Facility Reporting Requirements 01/01/2002
PIP 03 Alcohol & Drug Information System Reporting  01/01/2002
PIP 04 Policy & Procedures Management Rescind
PIP 05 Standards Compliance 01/01/2002
PIP 06 Satisfaction Survey  
PIP 07 Quality Assurance Committees 01/01/2002
     

10

Computer Use Policies (CUP)

 
CUP 01 Computer use Protocol  01/01/2002
CUP 02 Computer Virus 01/01/2002
CUP 03 Transmission Privacy 01/01/2002
CUP 04 User Names & Passwords 01/01/2002
CUP 05 SABHRS Application 01/01/2002
CUP 06 User Responsibility 01/01/2002
CUP 07 PC Replacement Cycle 01/01/2002
CUP 08 Work Station & Computer Care 01/01/2002
CUP 09 Computer Log On & Off 01/01/2002
CUP 10 Internet Service 01/01/2002
CUP 11 Network & File Security 01/01/2002
CUP 12 Work Station Computer Security 01/01/2002
CPU 13 Electronic Mail 01/01/2002
     

11

Transportation Policies (TRP)

 
TRP 01 Use of State Vehicle 11/01/2009
TRP 02 Employee Travel 01/01/2002
TRP 03 Transporting Bio-hazard Material 01/01/2002
TRP 04 Medical Emergency Transporting Patients   01/01/2002
TRP 05 Transporting Patients 11/01/2009
     

12

HIPAA Policies (HIPAAP)

 
HIPAAP 01 Privacy of Protected Health Information 2/27/2003
HIPAAP 02 Use and Disclosures of PHI 2/27/2003
HIPAAP 03 Minimum Necessary 2/27/2003
HIPAAP 04 Client Access to Protected Health Information 2/27/2003
HIPAAP 05 Amendment of PHI 2/27/2003
HIPAAP 06 Notice of Privacy Practices policy 2/27/2003
HIPAAP 07 Administrative Requirements 2/27/2003
HIPAAP 08 Documentation and Record Retention 2/27/2003
HIPAAP 09 Accounting for disclosures 2/27/2003
HIPAAP 10 Authorization Criteria 2/27/2003
HIPAAP 11 Complaint process 2/27/2003
HIPAAP 12 Employee Sanctions 2/27/2003
HIPAAP 13 Employee access to PHI 2/27/2003
HIPAAP 14 Physical security 5/13/2004
HIPAAP 15 Business Associate Agreements  2/27/2003
HIPAAP 16 Risk Assessment 1/1/2010
HIPAAP 16a Risk Assessment Tool 1/1/2010
HIPAAP 17 Duty to Notify 1/1/2010
HIPAAP 18 Notice of Protected Health Information 4/14/2003
     
Page last Updated: October 8, 2013