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37.106.1420    POLICY AND PROCEDURE MANUAL REQUIREMENTS

(1) Each service provider must develop and implement a policy and procedure manual that includes:

(a) the philosophy of the program;

(b) the program goals;

(c) a description of the population the facility is able to serve;

(d) procedures governing the treatment and care of adolescents, if served in the program;

(e) a delineation of all of the services to be provided;

(f) identification or a description of critical populations and mechanisms to address their needs;

(g) admission criteria which shall include at a minimum:

(i) how admissions will be prioritized;

(ii) program limitations and exclusions;

(iii) methods to be followed when a person is found ineligible for services; and

(iv) steps to follow for a wait list that includes how interim services will be provided when appropriate.

(h) procedures outlining how facilities and services shall provide for privacy and separation by gender;

(i) organizational chart showing:

(i) the lines and delegation of authority with supervisory responsibility clearly identified; and

(ii) responsibilities, structure, and reporting relationships explicitly stated and all staff positions delineated and functions identified.

(j) implementation process of state and federal regulations on client confidentiality, including at a minimum:

(i) providing written summary and verbal confidentiality notification at the time of admission or as soon thereafter as the client is capable of rational communication. The minimum required elements of the written summary must include but are not limited to the following:

(A) a general description of the limited circumstances under which a program may acknowledge that an individual is present at a facility or disclose outside the program information identifying a patient as an alcohol or drug abuser;

(B) a statement that information related to a patient's commission of a crime on the premises of the program or against personnel of the program is not protected; and

(C) a statement that reports of suspected child abuse or neglect made under state law to appropriate state or local authorities are not protected.

(k) a client grievance process;

(l) reporting requirements to notify the department within 24 hours by e-mail or fax; of a client, staff, volunteer, or visitor death where the death occurs on-site or in service related activities;

(m) reporting requirements to notify the department within 24 hours or next business day of any fire, accident, or other incident resulting in significant damage to the service site;

(n) reporting any suspected abuse or neglect in accordance with 41-3-201 or 52-3-811, MCA, to the state child abuse hotline at (866) 820-5437;

(o) notification of the department's licensing bureau in writing within 24 hours of any allegations of client abuse including child abuse or neglect and elder abuse or neglect:

(i) the provider must indicate in writing that the proper authorities have been contacted and the abuse or neglect reported.

(p) steps to ensure smoking is not permitted per the Montana Clean Indoor Air Act;

(q) the management, storage, and disposal of prescription and over the counter drugs if applicable; and

(r) client transportation, if provided by facility.

History: 50-5-103, 53-24-208, MCA; IMP, 50-5-101, 50-5-103, 53-24-207, 53-24-208, 53-24-306, 76-2-411, MCA; NEW, 2010 MAR p. 2975, Eff. 12/24/10.

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