Washington Administrative Code
Title 246 - Health, Department of
FACILITY STANDARDS AND LICENSING
Chapter 246-322 - Private psychiatric and alcoholism hospitals
Section 246-322-035 - Policies and procedures

Universal Citation: WA Admin Code 246-322-035

Current through Register Vol. 24-18, September 15, 2024

(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 C.F.R., 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.

Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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