WAC 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.