Washington Administrative Code › Title 246 - Health, Department of › FACILITY STANDARDS AND LICENSING › Chapter 246-322 - Private psychiatric and alcoholism hospitals › Section 246-322-035 - Policies and procedures

Current through Register Vol. 24-14, July 15, 2024
(1) The
				licensee shall develop and implement the following written policies and
				procedures consistent with this chapter and services provided:
(a) Criteria for admitting and retaining
				patients;
(b) Methods for assessing
				each patient's physical and mental health prior to admission;
(c) Providing or arranging for the care and
				treatment of patients;
(d) Assuring
				patient rights according to chapters 71.05 and 71.34 RCW, including posting
				those rights in a prominent place for the patients to read;
(e) Protecting against abuse and neglect and
				reporting suspected incidents according to the provisions of chapters 71.05,
				71.34, 74.34 and 26.44 RCW;
(f)
				Fire and disaster plans, including;
(i)
				Accessing patient-occupied sleeping rooms, toilet rooms and
				bathrooms;
(ii) Summoning internal
				or external resource agencies or persons, such as a poison center, fire
				department, and police;
(g) Emergency medical care, including:
(i) Physician orders;
(ii) Staff actions in the absence of a
				physician; and
(iii) Storing and
				accessing emergency supplies and equipment;
(h) Managing assaultive, self-destructive, or
				out-of-control behavior, including:
(i)
				Immediate actions and conduct;
(ii)
				Use of seclusion and restraints consistent with WAC
				246-322-180 and other applicable
				state standards; and
(iii)
				Documenting in the clinical record;
(i) Pharmacy and medication services
				consistent with WAC
				246-322-210;
(j) Infection control as required by WAC
				246-322-100;
(k) Staff actions upon:
(i) Patient elopement;
(ii) A serious change in a patient's
				condition, and immediately notifying family according to chapters 71.05 and
				71.34 RCW;
(iii) Accidents or
				incidents potentially harmful or injurious to patients, and documentation in
				the clinical record; and
(iv)
				Patient death;
(l)
				Smoking on the hospital premises;
(m) Responsibility for patients' personal
				property, including recording any valuables left on deposit with the
				hospital;
(n) Allowing patients to
				work on the premises, according to WAC
				246-322-180;
(o) Maintenance and housekeeping functions,
				including schedules;
(p) Cleaning,
				inspecting, repairing and calibrating electrical, biomedical and therapeutic
				equipment, and documenting actions;
(q) Transporting patients for:
(i) Diagnostic or treatment
				activities;
(ii) Hospital connected
				business and programs; and
(iii)
				Medical care services not provided by the hospital;
(r) Transferring patients to other health
				care facilities or agencies;
(s)
				Obtaining and retaining criminal history background checks and disclosure
				statements consistent with WAC
				246-322-030.
(t) Research involving patients;
(u) Clinical records consistent with WAC
				246-322-200, the Uniform Medical
				Records Act, chapter 70.02 RCW and Title 42 C.F.R., chapter 1, Part 2,
				10/1/89;
(v) Food service
				consistent with chapter 246-215 WAC and WAC
				246-322-230.