Montana Administrative Code

37.106.3102 MINIMUM STANDARDS FOR ABORTION CLINICS: LICENSING A clinic or other facility that performs surgical abortions or that provides abortion-inducing drugs to five or more patients each year must be licensed as an abortion clinic. The following are not abortion clinics and…

37.106.3103 MINIMUM STANDARDS FOR ABORTION CLINICS: PHYSICAL PLANT An abortion clinic must be constructed and maintained so as to prevent as much as possible the entrance and harborage of insects, rodents, and other vermin capable of transmitting disease including, without limita…

37.106.3104 MINIMUM STANDARDS FOR ABORTION CLINICS: POLICIES AND PROCEDURES Each abortion clinic must have a policy and procedure manual that is readily available to all facility staff, the department, and patients. A documented review/update to the policy and procedure manual mu…

37.106.3105 MINIMUM STANDARDS FOR ABORTION CLINICS: MEDICAL DIRECTOR QUALIFICATIONS An abortion clinic must have a medical director who has a current physician license in good standing with the Montana Board of Medical Examiners. The medical director must obtain 8 continuing educ…

37.106.3106 MINIMUM STANDARDS FOR ABORTION CLINICS: STAFF FILES The facility is responsible for maintaining a file on each employee. Employee files may be inspected by the department at any time. If the file is not maintained at the facility, it must be made available to the depa…

37.106.3107 MINIMUM STANDARDS FOR ABORTION CLINICS: PATIENT FILES An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following: patient identificatio…

37.106.3108 MINIMUM STANDARDS FOR ABORTION CLINICS: SANITATION Each abortion clinic must ensure the premises and equipment be kept clean and free of vermin capable of transmitting disease, including without limitation, rats, mice, mosquitos, and flies. An abortion clinic must pro…

37.106.3109 MINIMUM STANDARDS FOR ABORTION CLINICS: EMERGENCY PROCEDURES Staff trained in the use of emergency equipment and in cardiopulmonary resuscitation must be available whenever there is a patient in the abortion clinic. The following equipment shall be available to the op…

37.106.311 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: FOOD SERVICE ESTABLISHMENTS (REPEALED) Authorizing statute(s): 50-5-103, 50-5-404, MCA Implementing statute(s): 50-5-103, 50-5-204, 50-5-404, MCA History: NEW, 1980 MAR p. 1587, Eff. 6/13/80; TRANS, from DHES, 2002 MAR …

37.106.3110 MINIMUM STANDARDS FOR ABORTION CLINICS: ANESTHESIA The abortion clinic must: prohibit the use of flammable anesthesia; have a policy which defines the types of anesthesia that will be used within the abortion clinic; conduct an assessment prior to the patient's admiss…

37.106.3111 MINIMUM STANDARDS FOR ABORTION CLINICS: QUALITY ASSURANCE Abortion clinics must have a quality assurance program that: is ongoing; is data-driven; is broad in scope; addresses clinical and administrative issues as well as actual patient outcomes; has a defined set of …

37.106.3112 MINIMUM STANDARDS FOR ABORTION CLINICS: INFECTION PREVENTION AND CONTROL The abortion clinic must maintain an infection prevention and control program that seeks to minimize infections and communicable diseases. The abortion clinic is responsible for providing a plan …

37.106.3113 MINIMUM STANDARDS FOR ABORTION CLINICS: SAFETY The abortion clinic must designate a safety officer who is responsible for the facility's safety plan. The abortion clinic must have a safety program which addresses the organization's environment of care and safety for a…

37.106.3114 MINIMUM STANDARDS FOR ABORTION CLINICS: EMERGENCY PREPAREDNESS Abortion clinics must develop a written disaster plan in conjunction with emergency services in the community. Abortion clinics must conduct a review or physical exercise of such procedures at least once a…

37.106.312 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: BLOOD BANK AND TRANSFUSION SERVICES (REPEALED) Authorizing statute(s): Implementing statute(s): 50-5-103 and 50-5-404, MCA History: IMP, Sec. 50-5-103, 50-5-204 and 50-5-404, MCA; NEW, 1980 MAR p. 1587, Eff. 6/13/80; AM…

37.106.313 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: COMMUNICABLE DISEASE CONTROL All health care facilities shall develop and implement an infection prevention and control program. At a minimum, the facility must develop, implement, and review, at least annually, written…

37.106.314 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: MEDICAL RECORDS A health care facility must initiate and maintain a safe, secure, and confidential medical record for each patient, resident, or client. A health care facility, excluding a hospital, shall retain a patie…

37.106.315 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: EMPLOYEE FILES The facility is responsible for maintaining a file on each employee and substitute personnel. Employee files may be inspected by the department at any time. If the file is not maintained at the facility i…

37.106.316 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: SECURED CARE UNIT WITHIN A LICENSED LONG-TERM HEALTH CARE FACILITY All rules in this subchapter apply to secured care units. Special locking arrangements as specified in the "NFPA 101: Life Safety Code Handbook", 2012 E…

37.106.320 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: PHYSICAL PLANT AND EQUIPMENT MAINTENANCE Each facility must have a written maintenance program describing the procedures to keep the building, grounds, and equipment in good repair and free from hazards. A health care f…

37.106.321 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: ENVIRONMENTAL CONTROL A health care 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 tow…

37.106.322 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: DISASTER PLAN All health care facilities must develop a written disaster plan as follows: skilled nursing facilities (long-term care), outpatient centers for primary care, outpatient centers for surgical services, criti…

37.106.330 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: WRITTEN POLICY AND PROCEDURE A current written policy and procedure manual that describes all services provided in the health care facility must be developed, implemented, and maintained at the facility. The manual must…

37.106.331 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: LAUNDRY AND BEDDING If a health care facility processes its laundry on the facility site, it must: use rooms solely for laundry purposes; equip the laundry room with at least one mechanical washer and hot air tumble dry…

37.106.401 MINIMUM STANDARDS FOR A HOSPITAL: GENERAL REQUIREMENTS A hospital shall comply with the Conditions of Participation for Hospitals in 42 CFR subchapter G part 482. If a hospital provides skilled nursing care or intermediate nursing care, as those levels of care are defi…

37.106.402 MINIMUM STANDARDS FOR A HOSPITAL: MEDICAL RECORDS Medical records shall comply with the following requirements: A patient's entire medical record must be maintained, in either its original form or that allowed by ARM 37.106.314(3) , for not less than 10 years following…

37.106.403 MINIMUM STANDARDS FOR A HOSPITAL: HOSPITAL RECORDS Hospital records must be maintained. Authorizing statute(s): Sec. 50-5-103 and 50-5-404, MCA Implementing statute(s): Sec. 50-5-103, 50-5-106 and 50-5-404, MCA History: NEW, 1980 MAR p. 1587, Eff. 6/13/80; TRANS, from …

37.106.404 MINIMUM STANDARDS FOR A HOSPITAL: LABORATORIES A hospital laboratory shall comply with the Conditions for Coverage of Services of Independent Laboratories as set forth in 42 CFR 405.1310, 405.1311, 405.1314, 405.1316, and 405.1317. A copy of the cited rules is availabl…

37.106.405 MINIMUM STANDARDS FOR A HOSPITAL: ORGAN DONATION REQUESTS AND PROTOCOLS This rule is adopted to implement Chapter 219, Laws of 1987, which amended both the Uniform Anatomical Gift Act, Title 72, chapter 17, MCA, and the Montana Health Care Facility Licensing Act, Title…

37.106.410 MINIMUM STANDARDS FOR A HOSPITAL: CORONARY CARE UNIT If a hospital provides a coronary care unit, the unit shall comply with the following requirements: When a patient is cared for in a coronary care unit, a licensed registered nurse shall be on duty. At a minimum, the…

37.106.411 MINIMUM STANDARDS FOR A HOSPITAL: INTENSIVE CARE UNIT If a hospital provides an intensive care unit, the unit shall comply with the following requirements: When a patient is cared for in an intensive care unit, a licensed registered nurse shall be on duty. At a minimum…

37.106.420 MINIMUM STANDARDS FOR A HOSPITAL: OBSTETRICAL SERVICES If a hospital provides obstetrical services, the hospital shall comply with the following requirements: Obstetrical services must be under the supervision of a licensed registered nurse on a 24-hour basis. A matern…

37.106.421 MINIMUM STANDARDS FOR A HOSPITAL: NEWBORN NURSERY If a hospital provides a newborn nursery, the nursery shall comply with the following requirements: The newborn nursery must be under the supervision of a licensed registered nurse on a 24-hour basis. An individual bass…

37.106.422 MINIMUM STANDARDS FOR A HOSPITAL: PEDIATRIC AND ADOLESCENT SERVICES If a hospital provides pediatric and adolescent services, the hospital shall comply with the following requirements: Pediatric and adolescent services must be under the supervision of a licensed regist…

37.106.430 MINIMUM STANDARDS FOR A HOSPITAL: PSYCHIATRIC SERVICES If a hospital provides psychiatric services, the hospital shall comply with the following requirements: Psychiatric services must be under the supervision of a licensed psychiatrist on a 24-hour basis. Psychiatric …

37.106.440 MINIMUM STANDARDS FOR A HOSPITAL: RESPIRATORY THERAPY If a hospital provides respiratory therapy, the hospital shall comply with the following requirements: Respiratory therapy services must be under the supervision of a licensed physician appointed from the active med…

37.106.501 PURPOSE The purpose of these rules is to establish the minimum licensing requirements for the licensure of outpatient centers for surgical services. Authorizing statute(s): 50-5-103, MCA Implementing statute(s): 50-5-103, MCA History: NEW, 2013 MAR p. 1626, Eff. 9/6/13…

37.106.502 SCOPE For purposes of this subchapter, outpatient centers for surgical services include facilities described at 50-5-101(42), MCA. Authorizing statute(s): 50-5-103, MCA Implementing statute(s): 50-5-103, MCA History: NEW, 2013 MAR p. 1626, Eff. 9/6/13.

37.106.503 DEFINITIONS "Medical director" means a physician licensed under Title 37, chapter 3 MCA, who oversees the services provided in an outpatient center for surgical services. The medical director may also serve in the outpatient center as a licensed health care professiona…

37.106.506 MINIMUM STANDARDS FOR OUTPATIENT CENTERS FOR SURGICAL SERVICES An outpatient center must: meet the requirements of ARM Title 37, chapter 106, subchapter 3 relating to the minimum standards for all health care facilities; to the extent that other licensure rules in ARM …

37.106.507 WRITTEN POLICIES AND PROCEDURES Each outpatient center must maintain a policy and procedure manual. The policy and procedure manual must be reviewed by the medical director or administrator and updated as necessary, but at least annually. The manual must contain polici…

37.106.508 OPERATIONAL STANDARDS FOR OUTPATIENT CENTERS FOR SURGICAL SERVICES An outpatient center is organized under a governing body that sets policy and is responsible for the organization. This governing body must meet regularly, but at least quarterly. The outpatient center …

37.106.511 STAFFING AND PERSONNEL REQUIREMENTS Staffing and personnel requirements for an outpatient center for surgical services include: professional staff who are licensed under Title 37, MCA, to practice in their profession and have the knowledge and skills required to provid…

37.106.512 MEDICAL, CLINICAL, AND HEALTH RECORD INFORMATION An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following: patient identification; sig…

37.106.513 INFECTION PREVENTION, CONTROL, AND SAFETY The outpatient center must maintain an infection control program that seeks to minimize infections and communicable diseases. The outpatient center is responsible for providing a plan of action for preventing, identifying, and …

37.106.514 ANESTHESIA RISK AND EVALUATION The outpatient center must: prohibit the use of flammable anesthesia; have a policy which defines the types of anesthesia that will be used within the facility. Similarly, the outpatient center must address in this policy the level of Ame…

37.106.515 SURGICAL AND RELATED SERVICES Surgical procedures must be performed in a safe manner by qualified physicians functioning within their scope of practice and who limit the surgical procedures to those that are approved by the governing body in accordance to the facility …

37.106.601 MINIMUM STANDARDS FOR A SKILLED AND SKILLED/ INTERMEDIATE CARE FACILITY: GENERAL REQUIREMENTS A skilled nursing care facility shall comply with the Conditions of Participation for Skilled Nursing Facilities as set forth in 42 CFR subchapter G part 483. An intermediate …

37.106.605 MINIMUM STANDARDS FOR A SKILLED NURSING CARE FACILITY FOR EACH 24 HOUR PERIOD: STAFFING (REPEALED) Authorizing statute(s): 50-5-103, 50-5-404, MCA Implementing statute(s): 50-5-103, 50-5-204, 50-5-404, MCA History: Eff. 12/31/72; TRANS, from DHES, 2002 MAR p. 185; REP,…

37.106.606 MINIMUM STANDARDS FOR A SKILLED AND SKILLED/ INTERMEDIATE CARE FACILITY: DRUG SERVICES Medication shall be released to a patient at discharge only on the written authorization of his licensed physician. Self-administration of medication by a patient is not permitted ex…