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Rule Title: WRITTEN POLICIES AND PROCEDURES
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Department: PUBLIC HEALTH AND HUMAN SERVICES
Chapter: HEALTH CARE FACILITIES
Subchapter: Minimum Standards for Outpatient Centers for Surgical Services
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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37.106.507    WRITTEN POLICIES AND PROCEDURES

(1) Each outpatient center must maintain a policy and procedure manual. The policy and procedure manual must be reviewed by the medical director or administrator and updated as necessary, but at least annually. The manual must contain policies and procedures for:

(a) preadmission;

(b) patient education;

(c) preoperative assessment;

(d) postoperative assessment;

(e) observation and recovery;

(f) discharge planning;

(g) emergency procedures of the outpatient center to include information on the transfer agreement with the receiving hospital;

(h) anesthesia policies as described in ARM 37.106.514;

(i) business practices; and

(j) patient and staff security.

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

(3) Each outpatient center must have policies and procedures that address the criteria for clinical staff privileges and the process the governing body uses when reviewing physician credentials and determining whether to grant privileges.

(4) The outpatient center must implement a policy and a process which addresses the Food and Drug Administration (FDA) or manufacturer recall of drugs, vaccines, blood and blood products, medical devices, equipment, and supplies. The policy must address:

(a) the sources of information;

(b) methods for notifying staff;

(c) methods to determine if the recalled product is present at the facility;

(d) documentation of response to the recalled product;

(e) disposition or return of the recalled product; and

(f) patient notification as appropriate.

History: 50-5-103, MCA; IMP, 50-5-103, MCA; NEW, 2013 MAR p. 1626, Eff. 9/6/13.


 

 
MAR Notices Effective From Effective To History Notes
37-637 9/6/2013 Current History: 50-5-103, MCA; IMP, 50-5-103, MCA; NEW, 2013 MAR p. 1626, Eff. 9/6/13.
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