HEALTH CARE FACILITIES

37.106.1624 FOOD SERVICE A forensic mental facility (FMHF) must establish and maintain standards relative to food sources, refrigeration, refuse handling, pest control, storage, preparation, procuring, serving, handling food, and dish washing procedures that are sufficient to pre…

37.106.1701 SCOPE A behavioral health inpatient facility (BHIF) is intended to provide secured inpatient psychiatric treatment for up to 16 persons, 18 years of age or older, involuntarily committed or detained, or to persons seeking treatment voluntarily. While a BHIF is defined…

37.106.1702 PURPOSE The purpose of these rules is to establish minimum state health care facility/service licensing standards for secured nonhospital based inpatient psychiatric treatment for persons who may also have co-occurring substance use disorders; who are involuntarily co…

37.106.1703 APPLICATION OF OTHER RULES To the extent that other licensure rules in ARM Title 37, chapter 106, subchapter 3 conflict with the terms of this subchapter, the terms of this subchapter shall apply to a behavioral health inpatient facility. Authorizing statute(s): 53-21…

37.106.1704 DEFINITIONS For the purposes of this subchapter, the following definitions apply: "Administrator" means the person designated on the facility application or by written notice to the department as the person responsible for the daily operation of the facility and for t…

37.106.1705 LICENSE APPLICATION PROCESS Application for a health care facility/service license accompanied by the required fee shall be made to the Department of Public Health and Human Services, Quality Assurance Division, Licensure Bureau, 2401 Colonial Drive, P.O. Box 202953, …

37.106.1708 GOVERNING BODY The licensee must establish a governing body with responsibility for operating and maintaining the BHIF. The governing body must include the facility's medical director and the facility administrator. The governing body provides organizational guidance …

37.106.1709 MEDICAL DIRECTOR Each facility shall employ or contract with a medical director who shall: coordinate with and advise the staff of the facility on clinical matters; provide direction, consultation, and training regarding the facility programs and operations as needed;…

37.106.1710 ADMINISTRATOR RESPONSIBILITIES Each facility shall employ an administrator who shall: be responsible for operation of the facility at all times and shall ensure 24-hour supervision of the patients; maintain daily overall responsibility for the facility operations; dev…

37.106.1711 ADMINISTRATOR ABSENCE In the absence of the administrator, a staff member must be designated to oversee the operation of the facility during the administrator's absence. The administrator or designee shall be in charge, on call and physically available on a daily basi…

37.106.1712 DIRECT CARE AND OTHER EMPLOYEES Employees shall receive orientation and training in areas relevant to the employee's duties and responsibilities including: an overview of the facility's policies and procedure manual in areas relevant to the employee's job responsibili…

37.106.1713 PERSONNEL RECORDS The facility is responsible for establishing, maintaining, and securing a file on each employee, substitute personnel, intern, volunteer, and contractor. The following documentation from personnel files must be made available to the department at all…

37.106.1717 WRITTEN POLICIES AND PROCEDURES Each BHIF shall maintain a policy and procedure manual. The policy and procedure manual shall be reviewed and updated as necessary, but at least annually. The manual shall contain but not be limited to policies and procedures for: notif…

37.106.1718 CLINICAL RECORDS A patient clinical record shall be created upon the patient's admission to the BHIF. The clinical records must comply with the requirements of 53-21-165 and 53-21-166, MCA. Clinical records must be retained for five years following the date of dischar…

37.106.1719 PATIENT ASSESSMENTS The facility shall utilize a multidisciplinary team which may include but is not limited to the patient, social workers, addiction counselors, licensed mental health professionals, licensed practical nurses, mental health technicians, peer support …

37.106.1720 INDIVIDUALIZED TREATMENT PLANNING Based upon the findings of the assessment(s), the facility shall initiate an individualized treatment plan for each patient within 24 hours of admission. The treatment plan must conform to requirements outlined in 53-21-162, MCA, be c…

37.106.1724 RESTRAINT AND SECLUSION The facility must be capable of providing restraint or seclusion and must ensure that the restraint or seclusion is performed in compliance with 53-21-146, MCA. Restraint and seclusion must be performed in a manner that is safe, proportionate a…

37.106.1725 PATIENT RIGHTS Patients admitted to a behavioral health inpatient facility shall be afforded all of the rights of a patient provided for in Title 53, chapter 21, part 1, MCA, Treatment of the Seriously Mentally Ill. A copy of these rights shall be posted in a conspicu…

37.106.1726 SECURITY The facility shall develop security policies which address the following: securing the treatment unit; development of an emergency, fire, disaster, evacuation, and response plan; and summoning outside assistance from local emergency responders in the event of…

37.106.1727 QUALITY ASSESSMENT Each facility shall implement and maintain an active quality assessment program using information collected to make improvements in the facility's policies, procedures, and services. At a minimum, the program must include procedures for: conducting …

37.106.1730 DISCHARGE The patient must be provided with an aftercare plan upon discharge. Each facility shall prepare a discharge plan for each patient no longer receiving services. The discharge plan must include: the reason for discharge; a summary of the services provided by t…

37.106.1731 TRANSFER/DISCHARGE TO ANOTHER FACILITY A patient may be discharged and transferred to another facility pursuant to 53-21-111, MCA, at any time. Transfer protocols include but are not limited to: transferring facility will contact the receiving facility to determine if…

37.106.1735 PHYSICAL PLANT The building shall be considered an I - 2 occupancy for purpose of issuing a building permit. The building shall be classified as a New Health Care Occupancy or Existing Health Care Occupancy as found in Chapter 18 or Chapter 19 of the 2001, NFPA 101 - …

37.106.1736 COMMON USE AREAS At least two separate social spaces, one appropriate for noisy activities and one for quiet activities, shall be provided. The combined area shall be at least 25 square feet for each of the two spaces. This space may be shared by dining activities if …

37.106.1737 PATIENT TOILETS AND BATHING There must be at least one toilet available for every four patients in the facility. There must be at least one bathing unit for every six patients in the facility. A shower or tub is not required if the facility utilizes a central bathing …

37.106.1738 INFECTION CONTROL The facility must establish and maintain infection control policies and procedures sufficient to provide a safe environment and to prevent the transmission of disease. Such policies and procedures must, at a minimum, include the following: any employ…

37.106.1739 FOOD SERVICE Facilities shall comply with the regulations concerning food service establishments which are located at ARM Title 37, chapter 110, subchapter 2. Facilities shall provide for the patient's nutritional needs as prescribed by the patient's doctor. Authorizi…

37.106.1740 LAUNDRY AND HOUSEKEEPING Laundry and housekeeping services must be provided by the facility. A contracted service provider or the facility directly may provide laundry and housekeeping services. Facility administrators will ensure that provisions are made to accommoda…

37.106.1801 SPECIALTY MENTAL HEALTH FACILITY: APPLICATION OF OTHER RULES To the extent that other licensure rules in this chapter conflict with the terms of ARM 37.106.1802, 37.106.1805, 37.106.1810 through 37.106.1814, 37.106.1820, 37.106.1821, 37.106.1825 through 37.106.1829, 3…

37.106.1802 SPECIALTY MENTAL HEALTH FACILITY: DEFINITIONS As used in ARM 37.106.1801, 37.106.1802, 37.106.1805, 37.106.1810 through 37.106.1814, 37.106.1820, 37.106.1821, 37.106.1825 through 37.106.1829, 37.106.1831 through 37.106.1833, 37.106.1841 through 37.106.1845, 37.106.185…

37.106.1805 SPECIALTY MENTAL HEALTH FACILITY: MEDICAL RECORDS A specialty mental health facility must maintain a medical records system in accordance with written policies and procedures, as well as meet the following standards: Employ adequate personnel to ensure prompt and syst…

37.106.1810 SPECIALTY MENTAL HEALTH FACILITY: ORGANIZATIONAL STRUCTURE; GOVERNING BODY A specialty mental health facility must have a governing body that is legally responsible for the conduct of the facility and that: Ensures that the medical and professional staff of the facili…

37.106.1811 SPECIALTY MENTAL HEALTH FACILITY: ADMINISTRATOR A specialty mental health facility must have an administrator who has formal training and/or experience, preferably in the administration of a mental health facility, which demonstrates an ability to perform the function…

37.106.1812 SPECIALTY MENTAL HEALTH FACILITY: MEDICAL AND PROFESSIONAL STAFF A specialty mental health facility must: Have a single, organized professional staff with overall responsibility for the quality of all clinical care provided to patients and the professional practices o…

37.106.1813 SPECIALTY MENTAL HEALTH FACILITY: STAFF DEVELOPMENT A staff development program must be provided for administrative, professional, and support personnel, and must be supervised and directed by a staff committee or qualified person. Staff development programs must be o…

37.106.1814 SPECIALTY MENTAL HEALTH FACILITY: TREATMENT TEAM A specialty mental health facility must have a multi-disciplinary treatment team supervised and directed by the admitting psychiatrist, and consisting of adequate numbers of individuals licensed, registered, or certifie…

37.106.1820 SPECIALTY MENTAL HEALTH FACILITY: QUALITY ASSURANCE The governing body of the facility must ensure that there is an effective, ongoing, facility wide written quality assurance program and implementation plan in effect which ensures, monitors, and evaluates the quality…

37.106.1821 SPECIALTY MENTAL HEALTH FACILITY: UTILIZATION REVIEW A specialty mental health facility must have in effect a utilization review plan to review services furnished by the facility to patients, either through contracted services or by members of its medical staff to pat…

37.106.1825 SPECIALTY MENTAL HEALTH FACILITY: PHYSICAL PLANT Each patient room in a specialty mental health facility must meet the following standards: No more than four patients may be housed in a room. Patient room areas, exclusive of toilet rooms, closets, lockers, wardrobes, …

37.106.1826 SPECIALTY MENTAL HEALTH FACILITY: LIFE SAFETY AND BUILDING CODE A specialty mental health facility must be in compliance with the provisions of the 1994 National Fire Protection Association (NFPA) 101 Life Safety Code, chapters 22 and 23, residential occupancy. The de…

37.106.1827 SPECIALTY MENTAL HEALTH FACILITY: PHYSICAL ENVIRONMENT The facility must maintain adequate facilities for its services, the extent and complexity of facilities being determined by the services offered. The facility must be constructed, equipped, and maintained to prot…

37.106.1828 SPECIALTY MENTAL HEALTH FACILITY: ENVIRONMENTAL CONTROL A specialty mental health facility must be constructed and maintained so as to prevent entrance and harborage of rats, mice, insects, flies or other vermin. Hand cleansing soap or detergent and individual towels …

37.106.1829 SPECIALTY MENTAL HEALTH FACILITY: INFECTION CONTROL A specialty mental health facility must ensure that: the facility has an effective facility wide infection control surveillance program developed for the identification, investigation, prevention and control of nosoc…

37.106.1831 SPECIALTY MENTAL HEALTH FACILITY: EMERGENCY SERVICES The facility must ensure that patients have access to emergency services and to more intensive levels of care, including acute or inpatient psychiatric care. The facility must have an agreement with an outside sourc…

37.106.1832 SPECIALTY MENTAL HEALTH FACILITY: DISASTER PLAN A specialty mental health facility must develop a disaster plan in conjunction with other emergency services in the community which includes a procedure that will be followed in the event of a natural or man-caused disas…

37.106.1833 SPECIALTY MENTAL HEALTH FACILITY: LAUNDRY AND BEDDING If a specialty mental health facility processes its own laundry on the facility site, it must: Set aside a room for laundry and utilize it solely for that purpose. Equip the laundry with a mechanical washer and dry…

37.106.1841 SPECIALTY MENTAL HEALTH FACILITY: REQUIRED TREATMENT SERVICES A specialty mental health facility must: Provide an individually planned regimen of 24-hour evaluation, care, and treatment for each patient with mental health conditions associated with the addiction that …

37.106.1842 SPECIALTY MENTAL HEALTH FACILITY: FOOD AND NUTRITION SERVICES A specialty mental health facility must have nutrition services that are directed and staffed by adequate personnel and meet the following standards: The facility must assign an employee or contract with a …

37.106.1843 SPECIALTY MENTAL HEALTH FACILITY: NURSING SERVICES A specialty mental health facility must provide 24-hour nursing services and meet the following standards: The director of nursing services must be a licensed registered nurse and must: determine the types and numbers…

37.106.1844 SPECIALTY MENTAL HEALTH FACILITY: PHARMACEUTICAL SERVICES A specialty mental health facility must have pharmaceutical services that meet the needs of the patients and include either a pharmacy directed by a registered pharmacist or a drug storage area under the superv…