The Behavioral Health Partial Hospitalization Program Policy And Procedure Manual is part of MCN Healthcare’s ellucid® Policy Library. MCN Healthcare is the health care industry’s leading provider of TJC (formerly JCAHO) accreditation tools and CMS accreditation help, consisting of policy and procedure templates, forms, competencies and other compliance tools. MCN’s policy and procedure manuals are used in more than 25,000 healthcare organizations throughout the world to help with compliance, accreditation, and health care quality improvement.

All customizable policies, procedures, forms and compliance tools are provided as templates in Microsoft Word format. MCN’s policy and procedure library consists of 87 policy and procedure manuals and more than 18,000 compliance tools. This is the most comprehensive collection of customizable policy templates, policies, procedures, forms, competencies, job descriptions, and performance evaluations available anywhere—all kept up to date with the latest standards from CMS, Joint Commission, FDA, HIPAA, OSHA, ACHC, AAAHC, USP, and utilizing standards of practice from ANA, AORN, ENA, and more.

INTRODUCTION

Approval/Signature Sheet

Introduction

SECTION I - RIGHTS, RESPONSIBILITIES AND ETHICS

Patient Rights Policy

Patients' Legal and Human Rights Form

Patient Responsibilities

Advance Directives

Advance Directives Form

Tarasoff Warning

Tarasoff Warning - Weapons Prohibition

Patient Review of Medical Records

Confidentiality of Information - General Issues

Confidentiality

Notification to Staff of Presence at Partial Hospitalization Program Form

Staff Oath of Confidentiality Form

Photographing/Videotaping Patients

Consent to Photograph for Identification Form

Valuables - Patients' Personal Belongings/Contraband

Patient Complaints

Conduct of Clinical Trials/Research Projects

Investigational Drugs

Investigational Drug Information Record Form

Consent for Use of Investigational Drug - Sample Form

Staff Rights and Ethical Dilemmas in Patient Care

Resolution of Potential Conflict with Staff Member's Cultural/Ethical/ Religious Belief System

Corporate Compliance Plan

Conflict of Interest

SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES

Admission/Assessment

Patient Identification for Clinical Care and Treatment

Access to Services

Referral Process and Screening

Initial Intake Form

Nursing Intake Assessment Form

Admission Criteria

Exclusion Criteria

Certification

Physician Certification Form

Certification Language/Recertification Language Sample Form

Request for Voluntary Admission to the Partial Hospitalization Program and Authorization for Treatment Form

Admission Procedure

Assessments

Suicide Assessment

Psychosocial Assessment Form

Psychosocial Assessment Form - Update

Domestic Violence Assessment and Reporting

Report of Injuries by Assaultive or Abusive Conduct Form

Falls Precautions

Recognizing and Reporting Dependent Adult/Elder Abuse/ Neglect

Speech, Language and Hearing Services

Suspected Patient Abuse/Neglect

Vital Signs Record Sheet

Daily Nursing Note

Case Management

Liaison with Referral Source

"Hand-Off" Communication - Behavioral Health

Patient Care

Program Content

Therapeutic Milieu

Master Treatment Planning and Patient Care

Master Treatment Plan Form

Treatment Plan Review Form

Multidisciplinary Progress Note

Weekly Summary/Progress Report Form

Progress Record

Food Service

Emergencies - Medical

Management of Assaultive Behavior

Conduct to Minimize Violence

Program Violations - Patient Use of Drugs or Alcohol

Patient Education

Patient Orientation

Patient Orientation Checklist

Family Participation and Education

Patient Education

Discharge

Discharge Planning

Community Services Agency Referrals Form

Follow-Up

Transfer for Admission to Inpatient Psychiatric Setting

SECTION III - MEDICATION MANAGEMENT

Medication Self-Administration

Self-Administration of Medication Release Form

Current Medication List

SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control

Hand Hygiene

Employee Health Exam

SECTION V - IMPROVING ORGANIZATION PERFORMANCE

Performance Improvement Program - Performance Improvement Plan

Patient Satisfaction Survey

Risk Management

Performance Improvement Department - Notification Form

Sentinel Event

2006 JCAHO National Patient Safety Goals - Behavioral Health

SECTION VI - LEADERSHIP

Program Overview

Philosophy

Scope of Service

Standards of Excellence

Organizational Structure

Staffing

Staff Meetings

Petty Cash

Color-Coded Wristband System Safety

SECTION VII - MANAGEMENT OF HUMAN RESOURCES

Competency of Care Providers

Performance Evaluations

Position Description/Performance Evaluation - Partial Hospitalization Medical Director

Performance Evaluation - Age-Related Competency - Partial Hospitalization Medical Director

Annual Competency Clinical Skills Assessment - Partial Hospitalization Medical Director

Position Description/Performance Evaluation - Program Director - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Program Director - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Program Director - Partial Hospitalization

Position Description/Performance Evaluation - Case Manager/Therapist - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Case Manager/Therapist - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Case Manager/Therapist - Partial Hospitalization

Position Description/Performance Evaluation - Activity Therapist - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Activity Therapist - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Activity Therapist - Partial Hospitalization

Position Description/Performance Evaluation - Charge Nurse - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Charge Nurse - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Charge Nurse - Partial Hospitalization

Position Description/Performance Evaluation - Registered Nurse - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Registered Nurse - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Registered Nurse - Partial Hospitalization

Partial Hospitalization

Position Description/Performance Evaluation - Mental Health Worker/Driver - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Mental Health Worker/Driver - Partial Hospitalization

Annual Competency Clinical Skills Assessment - Mental Health Worker/Driver - Partial Hospitalization

Position Description/Performance Evaluation - Program Secretary/Unit Clerk - Partial Hospitalization

Performance Evaluation - Age-Related Competency - Program Secretary/Unit Clerk - Partial Hospitalization

Annual Competency Skills Assessment - Program Secretary/Unit Clerk - Partial Hospitalization

Volunteers

Code of Ethics - Students/Volunteers Form

Inservices

Employee Dress Code

Employee Personnel Records

The Privileging Process

Temporary Privileges

Medical Staff Reappointment and Renewal of Clinical Privileges

Fair Hearing Policy

SECTION VIII - MANAGEMENT OF INFORMATION

Management of Information Plan

Medical Records and Reports

Confidentiality Policy

Release of Information/Medical Record Consent Form

Release of Medical Record Form

Release of Substance Abuse Information or Medical Records Form

Notice of Prohibition of Redisclosure Form - Substance Abuse Program

Confidentiality of Substance Abuse Medical Records - Patient Notice Form

Authorization to Release Information and Pay Benefits Form

Protection and Availability of Medical Records

Patient's Certification, Authorization to Release Information and Payment Request Form

Medical Records Storage

Legibility of Medical Record Documentation

Documentation and the Use of Abbreviations, Acronyms and Symbols

Unacceptable Abbreviation and Symbol List

Documentation

Medical Records Content

Chart Documents Index

Registration Form

Verbal and Written Orders - General

Review of Medical Record