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246-324-030  <<  246-324-035 >>   246-324-040

PDFWAC 246-324-035

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; and
(ii) Documenting in the clinical record;
(i) Pharmacy and medication services consistent with WAC 246-324-210;
(j) Infection control as required by WAC 246-324-100;
(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 246-324-180;
(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 246-324-030;
(t) Research involving patients;
(u) Clinical records consistent with WAC 246-324-200, 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 246-324-230.
(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. WSR 95-22-013, ยง 246-324-035, filed 10/20/95, effective 11/20/95.]
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