Hospital Policies And Procedures

(1) The governing body must ensure that a written policies and procedures manual is maintained. In addition to meeting the requirements of rule 0940-05-06-.02 Policies and Procedures for all facilities, the manual must include the following elements: MINIMUM PROGRAM REQUIREMENTS FOR CHAPTER 0940-05-16 MENTAL HEALTH HOSPITAL FACILITIES (a) A quality assurance procedure for the assessment of the quality of care. This procedure must ensure appropriate treatment has been delivered according to acceptable clinical practice; (b) A written program description which must be available to staff, patients and members of the public. The description must include, but need not be limited to, the following: 1. Characteristics of the persons to be served, 2. Referral process, 3. Program rules for patients, and 4. Referral mechanisms for services outside the facility (both medical and non- medical); and (c) Procedures to ensure how the patient’s parents, guardian, members of the immediate family or other responsible adult are to be notified in the case of any unusual occurrence including serious illness, accidents or death.