(1) Each BHIF shall maintain a policy and procedure manual. The policy and procedure manual shall be reviewed and updated as necessary, but at least annually.

(2) The manual shall contain but not be limited to policies and procedures for:

(a) notifying staff of all changes in policies and procedures;

(b) addressing patient rights, including a procedure for informing patients of their rights;

(c) informing patients of the policy and procedures for patient complaints and grievances;

(d) addressing and reviewing ethical issues faced by staff and reporting allegations of ethics violations to the applicable professional licensing authority;

(e) admitting criteria and process to initiate behavioral treatment services to patients;

(f) developing procedures for the transfer of a patient to another hospital or facility;

(g) establishing fiscal policies governing the management of organizational and individual funds;

(h) developing and implementing policy(s) for security;

(i) establishing and maintaining a facility staffing procedure;

(j) assessment criteria for new admissions;

(k) informing patients of policies pertaining to secured treatment, suspension of treatment, transfer to other facilities, or discontinuation of services for voluntary patients;

(l) suspending or discontinuing facility services with the following information to be provided to the patient:

(i) the reason for suspending or discontinuing services or access to programs;

(ii) the conditions that must be met to resume services or access to programs;

(iii) the grievance procedure that may be used to appeal the suspension or discontinuation; and

(iv) what services, if any, will be continued to be provided even though participation in a particular service or program may be suspended or discontinued.

(m) referring patients to other providers or services that the facility does not provide; and

(n) conducting quality assessment and improvement activities.

(3) The policy and procedure manual must include a current organizational chart delineating the current lines of authority, responsibility, and accountability for the administration and provision of all facility patient treatment programs and services.

History: 53-21-194, MCA; IMP, 53-21-194, MCA; AMD, 2009 MAR p. 1801, Eff. 10/16/09.