WAC 246-322-035   Policies and procedures.  (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 CFR, chapter 1, Part 2, 10/1/89;

     (v) Food service consistent with chapter 246-215 WAC and WAC 246-322-230.

     (2) The licensee shall review and update the policies and procedures annually or more often as needed.



[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. 95-22-012, § 246-322-035, filed 10/20/95, effective 11/20/95.]