Ch. 1, § 5. Administrative Policies and Procedures

(a) In addition to any policies and procedures required by the Patients' Bill of Rights con- tained in section 4 of these rules, the hospital shall establish appropriate policies and procedures as required to implement and enforce these rules. Appropriate policies and procedures required to imple- ment and enforce these rules include but are not limited to the following: (i) Affirm and protect the patient's right stated under Section 4, to include: (A) Ensure that all allegations of mistreatment, abuse or neglect, as well as any injuries to patients, are reported immediately to the administrator or to other officials in accordance with State law and through established hospital standard reporting procedures; (B) Ensure that action is taken as necessary to prevent the potential of further abuse while an investigation is in process; (C) Provide for an immediate and thorough investigation of all allegations by trained, experienced personnel delegated with all necessary authority; results of all investigations must be reported to the administrator or designated representative, or to other officials in accordance with state law, within five working days of the incident; (D) Establish reasonable and appropriate corrective actions, including educa- tion, training and/or punishment for any hospital-affiliated individual who has been found to be respon- sible for acts of mistreatment, abuse or neglect of patients; (E) Prohibit the employment of individuals with a conviction or substantial documentation of child or patient abuse, neglect or mistreatment; (F) Provide training and informational materials on patients' rights and on the prevention of abuse/neglect/mistreatment for administrators, mental health professionals and direct care staff and volunteers; each new staff member should be presented this information at the time of employ- ment and training should be given for each of the groups at least annually. (ii) The hospital shall designate and staff an administrative function charged with the following responsibilities: (A) An assessment and report, to be submitted to the head of the hospital and the hospital's governing body on at least an annual basis, of the hospital's compliance or lack thereof with the requirements in these rules, and any applicable statutory, constitutional and accreditation stan- dards. (B) Establishment and implementation of procedure(s) which provide every person admitted to the hospital or any of its programs with adequate notice of the rights contained in these rules. (C) To act in the capacity of liaison for the hospital and its programs to the services and systems enumerated in provision 4(a)(xiii) of these rules. (iii) The hospital shall develop and implement an administrative procedure for the review of patient grievances with respect to the protection and enforcement of patients' rights, in com- pliance with provision 4(a)(xiii) of the Patients' Bill of Rights. This procedure shall include, but is not limited to the following elements: A formal procedure to assist patient's with problems or complaints will be provided to the patient. 1.  The complaint or grievance may be verbal or written and may be registered with the hospital designated patient representative or with the state designated patient advocate or with any external advocate the patient chooses. 2.  The complaint may be registered at any time. 3.  The names, addresses and telephone numbers of the hospital patient representative, the state patient advocate, and external advocacy organizations will be posted and/or otherwise made available to all patients. 4.  Access to external advocacy organizations will include contact information about: a) Protection and Advocacy, Inc.; b) Private attorneys; c) Legal services; d) Other mental health, legal and family consumer organizations; and e) The Chairman of the Wyoming State Mental Health Grievance Committee. 5.  If the patient chooses to file a formal grievance with the hospital, patient representative and/or with the state patient advocate: a) A response to the initial complaint will be made within twenty-four (24) hours, exclusive of weekends and holidays. b) The state patient advocate, the Human Rights Committee of the Wyoming State Hospital, and the head of the Wyoming State Hospital will work to resolve the grievance with the patient. c) If unresolved, the state patient advocate will present the patient's grievance to the Wyoming State Mental Health Grievance Committee for resolution.