Policy & Procedures
INDEX (ORG 10) |
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| An (A) indicates that a form accompanies the related policy . Example CUP 16 (A) | ||||||
| ORGANIZATIONAL OVERVIEW (ORG) | Effective | Revision | Review | |||
| Section I | Date | Date | Date | |||
| POLICY # | #PAGES | |||||
| Preface | ORG 01 | 1 page | 1/1/2002 | 3/10/2004 | ||
| Organizational Chart | ORG 02 | 1 page | 1/1/2002 | 3/10/2004 | ||
| Treatment Philosophy | ORG 03 | 2 pages | 1/1/2002 | 9/1/2002 | 3/10/2004 | |
| Guiding Principles & Working Guidelines | ORG 04 | 1 page | 1/1/2002 | 3/10/2004 | ||
| Organizational Code of Ethics | ORG 05 | 3 pages | 1/1/2002 | 3/10/2004 | ||
| Ethics Committee | ORG 06 | 4 pages | 1/1/2002 | |||
| Mission Statement | ORG 07 | 1 page | 1/1/2002 | 3/10/2004 | 3/10/2004 | |
| Goals & Objectives | ORG 08 | 2 pages | 1/1/2002 | |||
| Physical Plant Description | ORG 09 | 2 pages | 1/1/2002 | 3/10/2004 | 3/10/2004 | |
| Index | ORG 10 | 5 pages | 1/1/2002 | |||
| ADMINISTRATIVE POLICIES (ADP) | ||||||
| Section II | ||||||
| Americans with Disabilities Act (ADA) | ADP 01 | 3 pages | 1/1/2002 | 3/10/2004 | ||
| Visitors | ADP 02 | 2 pages | ||||
| Food Service | ADP 03 | 1 page | 1/1/2002 | |||
| Tobacco Use | ADP 04 | 2 pages | 1/1/2002 | 9/9/2002 | ||
| Bargaining Units | ADP 05 | 1 page | 1/1/2002 | |||
| Vending Machines | ADP 06 | 2 pages | 1/1/2002 | |||
| Office Machines | ADP 07 | 1 page | 1/1/2002 | |||
| Donations | ADP 08 | 3 pages | 1/1/2002 | 10/8/2003 | ||
| Supply Requests Forms | ADP 09 | 2 pages | 1/1/2002 | |||
| Service Animals | ADP 10 | 2 pages | 1/1/2002 | |||
| Weapons | ADP 11 | 2 pages | 1/1/2002 | |||
| Contract Management | ADP 12 | 2 pages | 1/1/2002 | |||
| Meal Sign In Log | ADP 13 | 2 pages | 7/1/2003 | |||
| Legal Intervention on Patients | ADP 14 | 2 pages | 10/30/2003 | |||
| Library Use Guidelines | ADP 15 | 1 page | ||||
| PERSONNEL POLICIES (PRP) | ||||||
| Section III | ||||||
| Volunteer Workers | PRP 01 | 4 pages | 1/1/2002 | |||
| Employee Conduct | PRP 02 | 3 pages | 1/1/2002 | |||
| Compensatory Time & Overtime | PRP 03 | 3 pages | 1/1/2002 | |||
| Personal Property in the Workplace | PRP 04 | 2 pages | 1/1/2002 | |||
| Chemical Dependency Interns | PRP 05 | 2 pages | 1/1/2002 | |||
| Chemical Dependency Trainees | PRP 06 | 2 pages | 1/1/2002 | 12/1/2002 | ||
| Sexual Harassment | PRP 07 | 4 pages | 1/1/2002 | 12/1/2002 | ||
| Licensure & Certification Requirements | PRP 08 | 2 pages | 1/1/2002 | 12/1/2002 | ||
| Recruitment & Hiring | PRP 09 | 4 pages | 1/1/2002 | |||
| Dress Code | PRP 10 | 2 pages | 1/1/2002 | 1/4/2005 | 2/17/2005 | |
| Professional Legal Testimony | PRP 11 | 2 pages | 1/1/2002 | |||
| Pay Plan | PRP 12 | 1 page | 1/1/2002 | |||
| New Employee Orientation | PRP 13 | 2 pages | 1/1/2002 | |||
| Staff Training and Development | PRP 14 | 2 pages | 1/1/2002 | |||
| Staffing Pattern | PRP 15 | 2 pages | 1/1/2002 | 2/23/2004 | 3/10/2004 | |
| Drug Free Workplace | PRP 16 | 3 pages | 1/1/2002 | 12/1/2002 | ||
| Drug Free Compliance Form | PRP 16(A) | 1 page | 1/1/2002 | |||
| Employee Performance Evaluations | PRP 17 | 2 pages | 1/1/2002 | |||
| EEO & Non-Discrimination | PRP 18 | 2 pages | 1/1/2002 | |||
| Leave Time | PRP 19 | 7 pages | 1/1/2002 | |||
| Leave Requests | PRP 20 | 3 pages | 1/1/2002 | |||
| Reporting Absence from Work | PRP 21 | 2 pages | 1/1/2002 | |||
| Employee Resignation | PRP 22 | 2 pages | 1/1/2002 | |||
| Disciplinary Action & Discharge | PRP 23 | 12 pages | 1/1/2002 | |||
| Grievance Procedure (Refer to M-O-M 3-0125, 6/2/97) MCDC Policy Rescinded | Rescinded | |||||
| Selective Service Compliance | PRP 25 | 5 pages | 1/1/2002 | |||
| Union Strike Plan | PRP 26 | 3 pages | 1/2/2003 | |||
| Staff Complaints-Concerns | PRP 27 | 3 pages | Rescinded | 6/16/2005 | ||
| Short Term Workers | PRP 28 | 2 pages | 3/26/2005 | |||
| MEDICAL RECORDS POLICIES (MRP) | ||||||
| Section IV | ||||||
| Health Information Compliance | MPR 01 | 7 pages | 1/1/2002 | |||
| Approved Medical Abbreviations | MRP 02 | 6 pages | 1/1/2002 | |||
| Records Security | MRP 03 | 3 pages | 1/1/2002 | |||
| Master Patient Index | MRP 04 | 2 pages | 1/1/2002 | |||
| Totally Integrated Electronic Record (TIER) not in book | MRP 05 | Not in Book | 1/1/2002 | |||
| Forms Approval Process | MRP 06 | 2 pages | 1/1/2002 | |||
| Documentation | MPR 07 | 2 pages | 1/1/2002 | |||
| CLINICAL TREATMENT POLICIES (CTP) | ||||||
| Section V | ||||||
| Admission & Screening & Scheduling | CTP 01 | 3 pages | 1/1/2002 | 10/1/2002 | ||
| Admissions Non-Discrimination | CTP 02 | 3 pages | 1/1/2002 | |||
| Consent for Treatment | CTP 03 (A) | 3 pages | 1/1/2002 | |||
| Scope of Chemical Dependency Services | CTP 04 | 2 pages | 1/1/2002 | |||
| Scope of Mental Health Services | CTP 05 | 2 pages | 1/1/2002 | 2/23/2005 | ||
| Length of Stay | CTP 06 | 2 pages | 1/1/2002 | 1/18/2005 | 2/23/2005 | |
| Individual Treatment Plans | CTP 07 | 2 pages | 1/1/2002 | |||
| Clinical Stay Review | CTP 08 | 3 pages | 1/1/2002 | 7/1/2003 | Change name on index to Continued stay review | |
| Hostile Patient Behavior | CTP 09 | 2 pages | 1/1/2002 | |||
| Patient Abuse | CTP 10 | 4 pages | 1/1/2002 | |||
| Patient Bill of Rights & Grievance | CTP 11 | 2 pages | 1/1/2002 | 6/16/2005 | 3/10/2005 | |
| Patient Bill of Rights | CTP 11 (A) | 2 pages | 1/1/2002 | |||
| Patient Grievance Procedure | CTP 12 | 4 pages | 1/1/2002 | 12/1/2002 | ||
| Patient Grievance Action Form | CTP 12 (A) | 1 page | 1/1/2002 | |||
| Patient Grievance Committee | CTP 13 | 2 pages | 1/1/2002 | 12/1/2002 | ||
| Patient Grievance Committee Form | CTP 13 (A) | 1 page | 1/1/2002 | |||
| Belongings Search & Safekeeping Unauth. Items | CTP 14 | 3 pages | 1/1/2002 | |||
| Safekeeping of Patient Valuables | CTP 15 | 2 pages | 1/1/2002 | |||
| Mental Health Assessment/Screening | CTP 16 | 3 pages | 1/1/2002 | 8/18/2005 | ||
| Suicidal Patients | CTP 17 | 3 pages | 1/1/2002 | 8/18/2005 | ||
| Patient Emergency Leave | CTP 18 | 2 pages | 1/1/2002 | |||
| Patient Therapeutic Leave Status | CTP 19 | 2 pages | 1/1/2002 | |||
| Transfer to Montana State Hosp. | CTP 20 | 2 pages | 1/1/2002 | |||
| Patient Elopement | CTP 21 | 4 pages | 1/1/2002 | |||
| Continued Care Planning | CTP 22 | 2 pages | 1/1/2002 | 10/30/2003 | ||
| Patient Discharge | CTP 23 | 5 pages | 1/1/2002 | |||
| Mental Health Discharge Coordination | CTP 24 | 2 pages | 1/1/2002 | 2/24/2005 | 2/17/2005 | |
| Disciplinary Discharge | CTP 25 | 3 pages | 1/1/2002 | |||
| Clinical Record Keeping Fed. Reg. Vol. 40 - No 127 Part IV, 07195 | CTP 26 | 5 pages | 1/1/2002 | |||
| Inter-disciplinary Staffing | CTP 27 | 2 pages | 1/1/2002 | |||
| Room Assignments | CTP28 | 1 page | 3/31/2003 | |||
| Patient Monitoring | CTP29 | 3 pages | 6/7/2005 | 2/24/2005 | 2/17/2005 | |
| Patient Belongings Received After Admission | CTP30 | 2 pages | 1/5/2005 | 2/24/2005 | 2/17/2005 | |
| Patient Haircuts | CTP31 | 2 pages | 2/17/2005 | |||
| INFECTION CONTROL POLICIES (ICP) | ||||||
| Section VI | ||||||
| Employee Tuberculosis Screening | ICP 01 | 4 pages | 1/1/2002 | |||
| Outline of exposure control Plan | ICP 02 | 4 pages | 1/1/2002 | |||
| Hand Washing | ICP 03 | 2 pages | 1/1/2002 | |||
| Clean up of Blood or OPIM | ICP 04 | 2 pages | 1/1/2002 | |||
| Hepatitis B Vaccination | ICP 05 | 2 pages | 1/1/2002 | |||
| Patient HIV Testing | ICP 06 | 2 pages | 1/1/2002 | |||
| Protective Equipment Location | ICP 07 | 2 pages | 1/1/2002 | |||
| Treatment of Pediculosis | ICP 08 | 4 pages | 1/1/2002 | |||
| Occupational Exposure | ICP 09 | 4 pages | 1/1/2002 | |||
| Infectious Control Guidelines | ICP 10 | 2 pages | 1/1/2002 | |||
| Cleaning Supplies | ICP 11 | 2 pages | 1/1/2002 | |||
| Laundry | ICP 12 | 2 pages | 1/1/2002 | |||
| Custodial | ICP 13 | 4 pages | 1/1/2002 | |||
| Tuberculosis Screening Patients | ICP 14 | 3 pages | 1/1/2002 | |||
| Autoclaving Stainless Steel Medical Equipment | ICP 15 | 2 pages | 1/1/2002 | |||
| MEDICAL & NURSING POLICIES (MNP) | ||||||
| Section VII | ||||||
| Nursing Admission Process | MNP 01 | 4 pages | 1/1/2002 | |||
| Admission of a Diabetic Patient | MNP 02 | 3 pages | 1/1/2002 | |||
| Acutely Intoxicated Patient | MNP 03 | 2 pages | 1/1/2002 | |||
| Change In Patient Status Form | MNP 04 | 2 pages | 1/1/2002 | |||
| Seizures Protocol | MNP 05 | 3 pages | 1/1/2002 | |||
| Anaphylactic Shock & Adrenalin Use | MNP 06 | 3 pages | 1/1/2002 | |||
| Glucagon Emergency Kit | MNP 07 | 3 pages | 1/1/2002 | |||
| Cardiopulmonary Resuscitation (CPR) | MNP 08 | 2 pages | 1/1/2002 | |||
| Out Patient Medical Referral | MNP 09 | 2 pages | 1/1/2002 | |||
| Medical Requests Xray, Emergency Surgical Need | MNP 10 | 2 pages | 1/1/2002 | |||
| Dental Service | MNP 11 | 2 pages | 1/1/2002 | |||
| Laboratory Specimen Collection | MNP 12 | 3 pages | 1/1/2002 | |||
| Medication Administration | MNP 13 | 9 pages | 1/1/2002 | 3/27/2002 | ||
| Buprenorphine Administration | MNP 13a | 9 pages | 8/18/2005 | |||
| Disposal of Patient Medication & Illegal Substances | MNP 14 | 3 pages | 1/1/2002 | |||
| Use of Ambulance Service | MNP 15 | 2 pages | 1/1/2002 | |||
| Unexpected Death | MNP 16 | 2 pages | 1/1/2002 | |||
| Depo-Provera Injections | MNP 17 | 4 pages | 1/1/2002 | 5/23/2001 | ||
| Patient receipt of personal medications | MNP 18 (A) | 1 pages | 1/1/2002 | |||
| Pregnant Patient | MNP 19 | 2 pages | 3/29/2002 | |||
| Insomnia Protocol | MNP 20 | 3 pages | 5/23/2002 | |||
| Medical Marijuana Policy | MNP 21 | 2 pages | 6/16/2005 | |||
| SAFETY POLICIES (STP) | ||||||
| Section VIII | ||||||
| Emergency Codes | STP 01 | 1 page | 1/1/2002 | |||
| Facility Security | STP 02 | 2 pages | 1/1/2002 | |||
| Incident Reports | STP 03 | 2 pages | 1/1/2002 | |||
| Employee Situation Reports | STP 04 | 2 pages | 1/1/2002 | |||
| Building Maintenance | STP 05 | 3 pages | 1/1/2002 | |||
| Disaster Response | STP 06 | 4 pages | 1/1/2002 | |||
| Fire Emergency | STP 07 | 5 pages | 1/1/2002 | |||
| Material Safety Data Sheets (MSDS) | STP 08 | 2 pages | 1/1/2002 | 1/14/2005 | 2/17/2005 | |
| Hand Held Radios | STP 09 | 2 pages | 1/1/2002 | |||
| Safety/Maintenance Inspections | STP 10 | 3 pages | 1/1/2002 | |||
| Locking & Unlocking Doors | STP 11 | 2 pages | 1/1/2002 | |||
| Explosions | STP 12 | 2 pages | 1/1/2002 | |||
| Bomb Threat | STP 13 | 2 pages | 1/1/2002 | |||
| Electrical & Water Outage | STP 14 | 2 pages | 1/1/2002 | |||
| Earthquake | STP 15 | 2 pages | 1/1/2002 | |||
| High Winds | STP 16 | 2 pages | 1/1/2002 | |||
| Thunderstorms | STP 17 | 2 pages | 1/1/2002 | |||
| Early Return to Work | STP 18 | 4 pages | 6/1/2003 | |||
| Patient Room Search | STP 19 | 2 pages | 10/23/2003 | |||
| Proper Lifting Techniques | STP 20 | 2 pages | 1/13/2005 | 1/15/2005 | 2/17/2005 | |
| Inoperable Elevators | STP 21 | 2 pages | ||||
| Hazard Communication Policy | STP 22 | 2 pages | ||||
| PERFORMANCE IMPROVEMENT POLICIES (PIP) | ||||||
| Section IX | ||||||
| Performance Improvement Committee | PIP 01 | 2 pages | 1/1/2002 | |||
| Facility Reporting Requirements | PIP 02 | 2 pages | 1/1/2002 | |||
| Alcohol & Drug Information System Reporting) | PIP 03 | 2 pages | 1/1/2002 | |||
| Policy & Procedures Management | PIP 04 | 2 pages | 1/1/2002 | |||
| Standards Compliance | PIP 05 | 1 page | 1/1/2002 | |||
| Satisfaction Survey | PIP 06 | 3 pages | 1/1/2002 | |||
| Quality Assurance Committees | PIP 07 | 2 pages | 1/1/2002 | |||
| COMPUTER USE POLICIES (CUP) | ||||||
| Section X | ||||||
| Computer use Protocol | CUP 01 | 8 pages | 1/1/2002 | |||
| Computer Virus | CUP 02 | 1 page | 1/1/2002 | |||
| Transmission Privacy | CUP 03 | 2 pages | 1/1/2002 | |||
| User Names & Passwords | CUP 04 | 2 pages | 1/1/2002 | |||
| SABHRS Application | CUP 05 | 1 page | 1/1/2002 | |||
| User Responsibility | CUP 06 | 3 pages | 1/1/2002 | |||
| PC Replacement Cycle | CUP 07 | 2 pages | 1/1/2002 | |||
| Work Station & Computer Care | CUP 08 | 2 pages | 1/1/2002 | |||
| Computer Log on & Off | CUP 09 | 2 pages | 1/1/2002 | |||
| Internet Service | CUP 10 | 2 pages | 1/1/2002 | |||
| Network & File Security | CUP 11 | 3 pages | 1/1/2002 | |||
| Work Station Computer Security | CUP 12 | 2 pages | 1/1/2002 | |||
| Electronic Mail | CPU 13 | 2 pages | 1/1/2002 | |||
| TRANSPORTATION POLICIES (TRP) | ||||||
| Section XI | ||||||
| Transportation | TRP 01 | 4 pages | 1/1/2002 | |||
| Employee Travel | TRP 02 | 2 pages | 1/1/2002 | 3/24/2005 | ||
| Transporting Bio-hazard Material | TRP 03 | 1 page | 1/1/2002 | |||
| Medical Emergency Transporting Patients | TRP 04 | 1 page | 1/1/2002 | |||
| Transporting Disruptive Patients | TRP 05 | 1 page | 1/1/2002 | |||
| HIPAA POLICIES (HIPAAP) | ||||||
| Section XII | ||||||
| Privacy of Protected Health Information | HIPAAP 01 | 3 pages | 4/14/2003 | |||
| Use and Disclosures of PHI | HIPAAP 02 | 7 pages | 4/14/2003 | |||
| Minimum Necessary | HIPAAP 03 | 3 pages | 4/14/2003 | |||
| Client Access to Protected Health Information | HIPAAP 04 | 3 pages | 4/14/2003 | |||
| Amendment of PHI | HIPAAP 05 | 3 pages | 4/14/2003 | |||
| Notice of Privacy Practices Policy | HIPAAP 06 | 3 pages | 4/14/2003 | |||
| Administrative Requirements | HIPAAP 07 | 3 pages | 4/14/2003 | |||
| Documentation and Record Retention | HIPAAP 08 | 7 pages | 4/14/2003 | |||
| Accounting for disclosures | HIPAAP 09 | 4 pages | 4/14/2003 | |||
| Authorization Criteria | HIPAAP 10 | 3 pages | 4/14/2003 | |||
| Complaint process | HIPAAP 11 | 2 pages | 4/14/2003 | |||
| Employee Sanctions | HIPAAP 12 | 2 pages | 4/14/2003 | |||
| Employee access to PHI | HIPAAP 13 | 3 pages | 4/14/2003 | |||
| Physical Security | HIPAAP 14 | 2 pages | 4/14/2003 | |||
| Business Associate Agreements | HIPAAP 15 | 2 pages | 4/14/2003 | |||
| Notice of Protected Health Information | HIPAAP 16 | 3 pages | 4/14/2003 | |||
Page last updated: 06/30/2006
