POLICY INDEX

CENTRAL STATE HOSPITAL
Policies/Procedures/Plans Index
Posted 10/30/2012
M- Middle Georgia Facility System
Blue - DBHDD/MHDDAD

NO.

TITLE

Date Posted Last Review/ Revision Date
1. Management and Organization Central State Hospital Organizational Charts
02-704 Process for Enrolling, Matching and Monitoring Host Homes/Life-Sharing Sites for DBHDD Developmental Disabilities Community Service Providers 07/01/10 06/2011
02-803 Health Risk Screening Tool (HRST) 03/01/11 06/2011
04-107 Requests for Waivers of the Standards for DBHDD Services 04/21/98 06/2011
1.00 Review/Establishment of CSH Policies/Procedures/Plans 11/18/10 11/18/10
1.01 Opinions from the State of Georgia Attorney General 8/19/08 06/2008
1.02 External Communications Among the Division of Mental Health, Regional Coordinators, Regional Hospitals and the Director of Regional Operations 8/19/08 06/2008
1.06 Emergency Interpretative Services for the Deaf 01/22/10 08/2009
1.07 Behavior Support 3/13/09 08/2008
1.09 End of Life 10/26/09 07/2009
1.09A End of Life 10/26/09 07/2009
1.12 Open Records Request Guidelines for Central State Hospital 6/23/09 03/2009
1.12A Open Records Request 6/23/09 06/2007
1.13 Computer Policies and Procedures 10/7/09 07/2009
1.30 Staff Holdover Policy 9/26/08 08/2008
2. Personnel
2.00 Competency Assessment Plan 7/21/06 05/2005
2.01 Hiring Salaries 1/18/05 01/2005
2.02 Clinical Supervision 12/03/10 10/2010
2.03 Notaries Public 8/19/08 06/2008
2.04 Business Ethics - Conflict of Interest 5/9/08 03/2008
2.05 Personal Appearance Dress Code    5/9/08 02/2008
2.09 Call-ins 10/26/09 07/2009
2.13 Position Actions 8/19/08 04/2008
2.16 Employee Recognition Program 3/25/08 02/2008
2.19 Compensation for Damaged/Destroyed Wearing Apparel 8/19/08 04/2008
2.20 Temporary Reassignment of Staff Outside of Current Job 9/26/08 06/2008
2.21 State Housing 5/9/08 02/2008
2.21A State Housing 5/9/08 02/2008
2.22 Engagement of Consultants 01/22/10 02/2008
2.22A Engagement of Consultants 01/22/10 02/2008
2.26 Polygraph Examinations 6/23/09 03/2009
2.30 Employee Assistance Referral Program 8/28/09 03/2009
2.31 Employee Wellness and Sports Program 9/26/08 08/2008
2.38 Employee Requests to be Excused from Client Care Duty 3/25/08 01/2008
3. Administrative Functions and Services
3.01 Entertainment DVDs and Video Cassettes (NEW) 3/25/08 02/2008
3.02 Forms Management 5/9/08 02/2008
3.03 State Property Management 5/16/08 05/2008
3.04 Utilization and Control of State-Owned Vehicles 01/22/10 08/2009
3.04A Utilization and Control of State-Owned Vehicles 08/30/09 08/2009
3.05 Communications Service 8/19/08 02/2008
3.05A Communications Service 8/19/08 02/2008
3.07 Requesting Operating Materials/Supplies from General Warehouse Asset Account 9/26/08 06/2008
3.07A Requesting Supplies from the General Warehouse 09/26/08 06/2008
3.08 Moving Large Items of Office Equipment and/or Furniture 8/19/08 06/2008
3.09 Employee Travel and Reimbursement for Travel 10/26/09 07/2009
3.09A Employee Travel and Reimbursement for Travel 05/04/10 07/2009
3.10 Payment of Fees for Organizational Memberships 8/19/08 04/2008
3.10A Payment of Fees for Organizational Memberships 8/19/08 04/2008
3.11 Warehouse Stock Items - Addition and Deletion 5/9/08 03/2008
3.11A Warehouse Stock Items - Addition and Deletion 5/9/08 03/2008
3.12 Purchasing Card 10/7/09 07/2009
3.12A Purchasing and Ordering of Supplies/Materials/Services 10/7/09 07/2009
3.13 Space Utilization 3/25/08 03/2008
3.14 Mail Service/Use of Inter-Office/Inter-Departmental Correspondence and Urgent Medical Info Envelopes 3/30/11 09/2010
3.15 Client Linen, Exchange and Control 5/9/08 05/2008
3.15A Client Linen, Exchange and Control 5/9/08 05/2008
3.15B Protocol Special Laundry Procedure 3/29/11 03/2001
3.16 Therapeutic Equipment Prescription Process 9/26/08 02/2008
3.16A Therapeutic Equipment Prescription Process 9/26/08 02/2008
3.17 Construction, Contracts, Processing, and Bidding 10/7/09 07/2009
3.18 Client Orientation 10/26/09 05/2009
3.18A Client Orientation 10/26/09 05/2009
3.21 Official and Unofficial Bulletin Boards 10/26/09 08/2009
3.22 Purchases From Petty Cash 10/26/09 07/2009
3.22A Purchases From Petty Cash 10/26/09 07/2009
3.23 Records in Litigation/Mortality Review 10/26/09 05/2009
3.24 Work Order Policy 5/16/08 03/2008
3.25 Comprehensive Client Assessment: Craig Center 03/09 04/2009
3.26 Infection Control During Construction and Renovation Projects 9/26/08 07/2008
3.27 Manufacturer's Recall of Supplies and/or Equipment 8/28/09 07/2009
3.29 Record of Care, Lost, Destroyed or Stolen Records 10/7/09 08/2009
4. Client Administration
2.104 Treatment and Release of Persons Committed to Hospitals by Virtue of a Finding of Incompetence to Stand Trial 10/26/09 03/2002
2.106 Initial Placement and Transfer of Forensic Patients, Hold-Order Patients, and Civil Patients Who Require Secure Treatment Settings 10/26/09 03/2002
2.108 Management and Release of Patients Acquitted as Not Guilty by Reason of Insanity 10/26/09 10/2005
23-100 Confidentiality and HIPAA 9/1/11 09/2011
23-101 Notice of Privacy Practices 9/1/11 09/2011
23-102 Reporting and Notification of Breaches 9/1/11 09/2011
23-103 Confidentiality and HIPPA Policy Complaints 12/1/11 12/2011
03-510 Seclusion or Restraint 11/21/11 11/2011
03-510 Review Seclusion or Restraint Review Form 12/2/11 12/2/11
6203-101 DHR DMHDDAD Guiding Principles Regarding Co-occurring Disorders 06/11/09  
6203-102 DHR DMHDDAD Guiding Principles Regarding Serving those with Co-occurring Behavioral Health Disorders and Developmental Disabilities 06/11/09  
6805-102 Management of Medication Brought to a State Hospital or Crisis Stabilization Program by a Consumer 7/1/09  
6805-304 Process for Qualifying People for the Mental Health Planning List and Mental Health Olmstead List 1/12/09  
03-508 Follow Up for Individuals Discharged from the State Hospital Who were on the Mental Health Olmstead List 10/06/10 09/2010
6805-701 Do Not Resuscitate (DNR) Orders 02/11/09 11/2008
03-514 Seizure Management 9/27/11 09/2001
4.00 Organizational Ethics and Individual Rights 01/22/10 09/2009
4.00A Client Rights and CSH Ethics Team 01/22/10 09/2009
4.01 Relationships Between Central State Hospital (CSH) Employees and Clients 5/9/08 01/2008
4.02 Private Professional Services for Clients 6/23/09 03/2009
4.03 Writ of Habeas Corpus/Judicial Supervision 3/25/08 01/2008
4.04 Central State Hospital (CSH) Client Satisfaction Survey 5/9/08 02/2008
4.05 Client Travel by Common Carrier 3/25/08 01/2008
4.06 Social Security/Medicare/Medicaid Benefits for Clients 10/7/09 06/2009
4.06A Social Security/Medicare/Medicaid Benefits for Clients 10/7/09 06/2009
4.07 Non-Discrimination In Services 3/25/08 02/2008
4.10 Clients' Identification Photographs 8/19/08 06/2008
4.10A Clients' Identification Photographs 8/19/08 06/2008
4.12 Notification of Law Enforcement Officer Upon Release of Clients 6/23/09 10/2008
4.12A Notification of Law Enforcement Officer Upon Release of Clients 6/23/09 10/2008
4.13 Clients' Funds and Personal Effects 9/26/08 04/2008
4.13A Clients' Funds and Personal Effects 9/26/08 04/2008
4.16 Interstate Transfer of Clients 04/04/11 09/2010
4.16A Interstate Transfer of Clients 04/04/11 10/2009
4.17 Transfer of Clients to CSH within the Division of MH/DD/AD Facilities 01/22/10 08/2009
4.18 Notification to Authorized Representative of His/Her Rights to Consultation and Involvement in the Client's Treatment Plan 01/22/10 04/2005
4.18A Notification to Authorized Representative of His/Her Rights to Consultation and Involvement in the Client's Treatment Plan 01/22/10 04/2005
4.19 Day Passes, Temporary Leaves and Trial Visits 3/18/08 01/2006
4.19A Day Passes, Temporary Leaves and Trial Visits 3/10/06 01/2006
4.20 Client Accident and Injury Report 3/18/08 01/2004
4.20A Client Accident and Injury Report 1/27/04 01/2004
6801-101 Legal Status of Persons Admitted to DMHDDAD Hospitals 4/15/09 05/2009
4.21 Coding and Tracking of Court Orders and Georgia Department of Corrections Admissions (Commitment Types 244, 201, 204, 205, 206, 241, and 243 9/2608 04/2008
4.21A Coding and Tracking of Court Orders and Georgia Department of Corrections Admissions (Commitment Types 244, 201, 204, 205, 206, 241, and 243 9/26/08 04/2008
4.22 Client Access to Telephone Communication 3/25/08 02/2008
4.23 Criminal Prosecution of Clients 3/30/11 01/2011
4.24 Transition of Central State Hospital (CSH) Non-Forensic Clients 6/2/09 03/2008
4.26 Elopement/Escape 10/06/10 09/2010
4.28 Relationship with the Ga. Advocacy Office (GAO) 3/24/08 02/2008
4.29 Confidentiality 3/25/08 11/2007
6805-201 Criteria for Admission to DHR DMHDDAD Hospitals for Persons with Mental Illness 06/11/09 03/2008
6805-202 Admission and Discharge of Consumers in Need of Temporary and Immediate Care (Effective 3-17-08) 3/6/08 03/2008
03-520 Medical Evaluation Guidelines and Exclusionary Criteria for Admission 09/08/11  
4.31 Continuity of Care, Transition Planning and Medical Alert 6/1/09 04/2008
4.32 Alleged Sexual Assault on a Client 02/03/11 09/2010
4.32A Alleged Sexual Assault on a Client 02/03/11 09/2010
4.33 Client Visits and Visitor's Responsibilities 9/26/08 04/2008
4.34 Intrahospital Transfer of Clients 12/06/05 09/2005
4.35 Nursing Home Referral and Placement for Clients 01/22/10 07/2009
4.35A Nursing Home Referral and Placement for Clients 3/10/06 07/2009
4.36 Right to Consent/Refuse 01/22/10 07/2009
22-1603 Personnel Action in Cases of Abuse, Neglect and/or Exploitation 09/02/10  
4.37 Allegations of Client Abuse - Investigative & Employees Action to be Taken 02/03/11 09/2010
4.38 Non-Local and Overnight Activities for Clients 9/26/08 02/2008
4.38A Non-Local and Overnight Activities for Clients 9/26/08 02/2008
4.39 Organ Donation 10/26/09 08/2009
4.40 Clients with Infectious or Communicable Disease; Notification to Emergency Response Employee (ERE) 3/24/08 02/2008
4.40A Clients with Infectious or Communicable Disease; Notification to Emergency Response Employee (ERE) 3/24/08 02/2008
4.41 Medical Services for Pregnant Clients 10/7/09 09/2009
4.41A Medical Services for Pregnant Clients 10/7/09 09/2009
4.42 Advance Directives: Client Self-Determination in the Planning of Medical and/or Surgical Treatment for Physical Conditions 8/19/08 03/2008
4.42A Advance Directives: Client-Self Determination in the Planning of Medical and/or Surgical Treatment for Physical Conditions 8/19/08 03/2008
4.43 Education Services 6/2/09 03/2008
4.45 Client and Family Education 3/25/08 01/2008
M4.46B(2.02) Suspected or Alleged Abuse Occurring Prior To Admission, or During Trial Visit/Temporary Leave 5/8/03 09/2002
4.46 Victims of Suspected Abuse or Neglect 07/28/10 08/2009
4.47 Adaptive Supportive 6/2/09 02/2008
4.48 Medical Protective 5/9/08 02/2008
4.49 Medical Immobilization 5/9/08 02/2008
03-522 Physical and Nutritional Supports 12/03/10 06/2010
03-522 Physical and Nutritional Support Risk Screen Attachments 7/6/11 07/2011
4.50 Diet Orders and Diet Changes 6/28/11 02/2008
4.51 Pain Assessment and Management 9/26/08 09/2008
4.52 Self - Administration of Medication 6/2/09 02/2008
4.52A Self - Administration of Medication 6/2/09 02/2008
03-501 Observation of Individuals to Ensure Safety 12/29/10 11/2010
4.54 Use of Minimal Sedation for Clinic Appointments and Diagnostic Procedures 4/09 12/2004
4.57 Moderate/Deep Sedation Care 6/2/09 03/2008
4.58 Medical Staff Communication Report CSH Physician Notes 5/9/08 02/2008
4.59 Hand-Off Communications 5/16/08 04/2008
2.100 Informed Consent and Involuntary Administration of Medication 1/16/08 11/2007
4.60 Use of Psychotropic STAT/PRNs Meds 11/18/10 11/2010
4.61 Clinical Institute Withdrawal Assessment for Alcohol (CIWA) 3/14/08 01/2008
4.62 Use of Psychotropic Medications/Psychotropic Medication Reviews 10/06/10 09/2010
4.63 Care of the Client with Head Trauma (New) 04/20/09 03/2008
4.64 Recognition and Management of Pressure Ulcers 7/6/11 03/2011
4.65 Client Employment 7/09 07/2008
4.67 Code Yellow    10/26/09 10/2009
4.68 Change of Status   1/22/10 12/2009
4.69 Dining Room & Meal Supervisor  1/31/11 02/2011
6805-602 Actions Necessary Upon Death of a Consumer 02/20/09 02/2009
03-525 Mortality Review Process 02/02/11 12/2010
03-532 Medication Formulary 8/11/11 08/2011
5. Safety and Protection of Persons and Property
03-515 DBHDD Incident Management Policy 8/23/10 11/2011
  Special Investigations Manual 5/27/10  
03-505 Medication Variance Reporting & Analysis 10/06/10 09/2010
03-524 Adverse Drug Reaction 10/06/10 09/2010
03-529 Medication Reconciliation at Admission and Transfer 09/08/11 10/2011
6805-601 Sentinel Events 04/20/09 03/2009
5.01 Institution Police Authority and Relationships with Other Law Enforcement Agencies 6/23/09 03/2009
5.02 Control of Firearms and Other Prohibited Items 10/7/09 09/2009
5.03 Occupational Health & Injury Service 9/26/08 08/2008
5.04 Ambulance and Non-Emergency Transport Service 3/25/08 01/2008
5.04A Ambulance and Non-Emergency Transport Service 3/25/08 01/2008
5.05 Transport of Ambulatory Individuals 2/02/11 02/2011
5.07 Emergency Management of Pregnant Women 9/26/08 07/2008
5.08 Lost and Found Property 6/2/3/09 03/2009
03-504 Suicide, Violence and Victimization Risk Assessment 09/01/11 10/2009
5.09 Suicidal Precautions 6/14/05 05/2005
5.09A Suicidal Precautions 6/14/05 05/2005
5.10 Notice of Possibility of Claim 10/7/09 09/2009
5.12 Property/ Contents and All Risk Insurance 8/28/09 07/2009
5.13 Liability and Bond Coverage 6/2/09 03/2009
5.14 Key Control 8/28/09 03/2009
5.15 Accidents Involving State Vehicles 5/9/08 02/2008
5.15A Accidents Involving State Vehicles 5/9/08 02/2008
15.103 Smoke-Free Environment in DHR DMHDDAD Facilities 6/11/09 06/2007
03-201 Tobacco Free and Smoke Free Environment in DBHDD Facilities 1/22/10  
5.16 Restriction of Tobacco and Smoking Materials on Central State Hospital Campus 09/10 09/2010
5.17 Safe Medical Devices and Laboratory Product Reporting 01/22/10 09/2009
5.17A Safe Medical Devices and Laboratory Product Reporting 01/22/10 09/2009
5.19 Medication Reconciliation 2/11/09 12/2006
03-202 Crash Cart Locations, Supplies, and Drills 10/26/09 10/2009
03-203 CPR, AED and First Aid Certification Requirements 1/22/10 01/2010
03-205 Medical Emergency Response System for Central State Hospital 05/23/11 12/2011
03-206 Medical Emergency Respiratory Support for Central State Hospital 05/23/11 12/2011
03-207 Automated External Defibrillator Use for Central State Hospital 05/23/11 12/2011
5.20A Cardiopulmonary Resuscitation / Code Blue 12/8/09 10/2009
5.21 Biomedical Equipment Management 01/22/10 05/2009
5.22 Notification of Escapes from Georgia Department of Corrections  Complex 10/26/09 05/2009
5.23 Pre-Admission Search 10/7/09 05/2009
5.23A Pre-Admission Search 10/7/09 05/2009
5.24 Fire Rated or Smoke Tight Wall Penetrations 9/02/10 06/2010
5.25 Storage and Disposal of Drug Samples 5/16/08 04/2008
5.25A Storage and Disposal of Drug Samples 5/16/08 04/2008
5.26 Wheelchair/Geriatric Chair Repair/Purchases 6/23/09 03/2008
5.27 Elevation & Degrees of Variance for Wheel Chairs Geri Chairs & Beds 01/31/11 02/2011
03-204 Emergency Code Designations for State Hospitals 1/22/10 01/2010
5.28 Transporting Clients in a Wheelchair Bus/Vehicle 8/28/09 10/2008
5.28A Transporting Clients in a Wheelchair Bus/Vehicle 8/28/09 10/2008
6. Relationships with the Public and Other Governmental Agencies
6.01 Collections and Solicitations 6/23/09 11/2008
6.02 Resources Services 6/23/09 12/2008
6.03 Use of Hospital Facilities By Outside Groups 6/23/09 12/2008
6.04 Release of Information to News Media and Attorneys; and Publication of Articles 01/22/10 08/2009
6.06 Utilization of Middle Georgia Correctional Complex Inmates 8/19/08 06/2008
6.06A Utilization of Middle Georgia Correctional Complex Inmates 8/19/08 06/2008
7. Training and Research
03-402 Safety Care Training & Certification 01/31/11 12/2010
7.01 Staff Development & Training 10/7/09 07/2009
7.02 Research 8/19/08 05/2008
7.02A Research 8/19/08 05/2008
7.03 Educational Assignment (EA) Policy 6/28/11 05/2011
7.04 Student Affiliation Agreements (a.k.a. Internships) 01/07/08 10/2007
8. Plans
8.00 Client Safety Plan 8/21/06 07/2006
8.01 Emergency Preparedness Manual 1/22/10 08/2009
8.02 Interim Life Safety Measures 5/9/08 03/2008
8.03 Fire Safety 5/9/08 02/2008
8.04 Safe Use Handling and Storage of Flammable and Combustible Liquids 5/9/08 04/2008
8.06 Motor Vehicle and Traffic Regulations 10/7/09 07/2009
8.07 Utilities Management Plan 1/22/10 08/2009
8.08 Safety Management Plan 10/26/09 07/2009
8.10 Performance Improvement Plan 6/23/09 01/2009
8.11 Plan for Care 10/26/09 07/2009
8.15 Hazardous Materials and Wastes Management 9/24/10 09/2010
03-601 Risk Management 01/31/11 12/2011
8.17 Compliance Plan 8/19/08 05/2008
8.18 Use Of Anticoagulant Medications 11/17/10 11/2010