OSH Policy & Procedures

Here’s a recent set of policies and procedures for the Oregon State Hospital. Looks like most of them are from 2011.

Executive Summaries

1.003 Executive Summary 2-13
1.012 Executive Summary
2.003 Executive Summaryc
2.005 Executive Summary
2.006 Executive Summary
2.009 Executive Summary 2-13
4.006 Executive Summary
4.015 Executive Summary 2-13
5.001 Executive Summary
5.004 Executive Summary
5.005 Executive Summary
5.007 Executive Summary
5.022 Executive Summary 2-13
5.024 Executive Summary
5.025 Executive Summary 2-13
6.001 Executive Summary
6.006 Executive Summary
6.011 Executive Summary
6.023 Executive Summary
6.042 Executive Summary
6.047 Executive Summary
6.048 Executive Summary
6.053 Executive Summary
6.054 Executive Summary 2-13
7.004 Executive Summary
8.003 Executive Summary
8.019 Executive Summary
8.021 Executive Summary
8.026 Executive Summary
8.030 Executive Summary
8.031 Executive Summary
8.033 Executive Summary
8.036 Executive Summary


Full Policies & Procedures

1.001 Policies and Procedures
1.002 Drafting Processes for Policies and Procedures
1.003 Incident Reporting
1.004 Performance Improvement Program
1.005 Information Technology Hardware and Software
1.006 Patient Motor Vehicle Use – Determining Ability to Use a Motor Vehicle
1.007 Patient Transfers from Oregon State Hospital
1.008 Oregon State Hospital Toll-Free Telephone Numbers
1.009 Tours at Oregon State Hospital
1.010 Institutional Review Board for Research
1.011 Space Utilization and Management
1.012 Alternate Formats for Interpersonal Communications
1.013 Acceptable Use of Information-Related Techology
2.001 Infection Control Program
2.002 Tuberculosis Survellance and Management of Employees, Volunteers, Students
2.003 Employee with Infectious Disease,Infection Control Issues
2.004 Tuberculosis Surveillance and Management for Patients
2.005 Ordering Laboratory Tests, Collecting, Handling…
2.006 Records Retention and Destruction Attachment 1
2.006 Records Retention and Destruction
2.007 Medical Records
2.008 Confidentiality and Security of Patient Information
2.009 Medical Record Forms Management
2.010 Notification Regarding Fire Setters and Arsonists
2.011 Animals Within the Hospital
2.012 Sentinel Events
2.014 Medical Record – Handling, Transportation, and Maintenance A1 Attachment
2.014 Medical Record – Handling, Transportation, and Maintenance
3.001 Requesting Emergency and Maintenance Service…
4.001 Food Safety for Patient Activities
4.002 Housing for Employees
4.003 Distribution of Payroll Checks
4.004 Patient Benevolent Fund
4.005 Use of the OSH Visitors Cottage
4.006 Meal Services for Employees and Guests
4.007 Capital and Non-Capital Assets
4.008 Peggy Ross Trust Fund
4.009 Handling Personal Property and Valuables
4.010 Handling of Patients’ Funds
4.011 Donations and Contributions
4.012 Purchase of Outside Medical Services-Durable Medical Equip
4.013 Membership, Dues and Licenses
4.014 Procurement of Goods, Services, and Personal Services
4.015 Retail Services for Patients
4.016 Overtime Recordkeeping Procedure
4.017 Small Purchase Order Transaction System [Spots] Card
4.018 MDC Receiving _ Inventory Control Services Supplies
5.001 Drug-Free Workplace
5.002 Family Medical Leave
5.003 Electronic Access to Oregon Driver License Records and…
5.004 Valuing Diversity
5.005 Use of Personal Equipment
5.006 Employee Recognition
5.007 The Employee with HIV Infection, Personal Issues
5.007 The Employee with HIV Infection, Personnel Issues DAS Policy 50.020.10
5.008 Equal Opportunity Employment-NonDiscrimination
5.009 Staff-Patient Relationships
5.010 Tobacco-Smoke-Free Facility
5.011 Return to Work of Employees Injured on the Job
5.012 Reporting of Injurious _ Illnesses
5.013 General Leave Policy
5.014 Conflict of Interest
5.015 Employee Separation Procedure
5.016 Inmate Work Force
5.017 Dress Wear of Staff and Volunteers
5.018 Volunteers
5.019 Employee Health
5.020 Staff-Volunteer-Inmate Worker Relationship
5.021 Employee, Contractor and Volunteer Criminal Offender Information
5.022 Competency Assessment
5.023 Nepotism
5.024 Trauma Response Program
5.025 Maintaining a Professional Workplace
5.026 Staff Suggestion Program
5.027 Performance Management Plan
6.001 Transfers within OSH and to Outside Hospitals
6.002 Reporting of Patients on Pass
6.003 Use of Seclusion or Restraint
6.004 Medical-Surgical Care of OSH Patients
6.005 The Deceased Patient
6.006 Off-Grounds Outings
6.007 Interstate Repatriation of Patients
6.008 Screening Patients for Tardive Dyskinesia
6.009 Patient Pay at Oregon State Hospital

6.010 Behavioral Precautions

6.011 Interdisciplinary Treatment Team Process Attachment 1

6.011 Interdisciplinary Treatment Team Process Attachment 2

6.011 Interdisciplinary Treatment Team Process
6.012 Do Not Resuscitate (DNR) Order
6.013 Discharge and Continuing Care Planning
6.014 Organ Donation
6.015 Audiometric Screening
6.016 Sexual Activity Between Patients
6.017 Personal Searches
6.018 Human Immunodeficiency Virus (HIV)
6.019 Designation of Medical Condition When a Patient ….
6.020 Language Services for Patients
6.021 Communication With Patients’ Family or Significant Others
6.022 Behavior Supervision
6.023 Early Intervention Techniques, Including Use of Movement..
6.024 Curfew
6.025 Advance Directives – Medical
6.026 Psychiatric Triage at OSH-Portland

6.027 Restrictive Event Reporting Including Seclusion or Restraint
6.028 Patient and Family Education
6.029 Forensic Risk Review Panel
6.030 Computer and Internet Access for OSH Patients
6.031 Screening, Management and Treatment of Patients at Risk of Dysphagia
6.033 Patient Profile
6.034 Tobacco-Smoke-Free Facility
6.035 Medication Reconciliation
6.036 Gambling Activity
6.037 Anticoagulation Therapy
6.038 Supporting Patients’ Treatment Mall Participation
6.039 Acute Milieu Emergency Policy
6.040 Patient Wellness
6.041 Screening and Care of Patients with Metabolic Syndrome and Diabetes Mellitus
6.042 Short-Term Assessment of Risk and Treatability (START) Attachment 1
6.042 Short-Term Assessment of Risk and Treatability (START) Attachment 2
6.042 Short-Term Assessment of Risk and Treataibility (START)
6.043 Adult Treatment Services Risk Review Panel
6.043 Attachment 1 (ATS Risk Review)
6.044 Guardianship-Conservatorship

6.045 Attachment 1

6.045 Attachment 2

6.045 Clinical Documentation
6.046 Patient Fall Prevention Fall Risk Screening, Assessment, and Management
6.047 Guidelines for Patient Food
6.048 The Recovery Environments Actively Creating Hope (REACH) Program
6.049 Admission of Patients with Medical Problems
6.050 Bandage and Dressing
6.052 Attachment A
6.052 Attachment B
6.052 Attachment C
6.052 Attachment D
6.052 Trauma-Informed Care Screening, Assessment, Txt Planning

6.053 Referral of Patients 18-21 Years of Age to Local….

6.054 Critical Values-Results

6.055 Medication Management
6.057 Trails Leaf 2 Privilege Process
7.001 Handling of Patients’ Mail
7.002 Objectionable Material and or Subjects Unsuitable for Viewing by Patients
7.003 Attachment 2
7.003 Photographing, Videotaping or Naming of Patients and Use Attachment 1
7.003 Photographing, Videotaping or Naming of Patients and Use..
7.004 Use of Audio,Video Recording Devices
7.005 Patient Rights
7.006 Patient Grievances
7.007 Visitation of Patients by Pastoral Visitors-Volunteers
7.008 Abuse of Hospitalized Patients…..
7.009 Voter Registration and Voting
7.010 Section 504 Grievance Procedure for Patients with Disabiliy
7.011 Religious Beliefs and Practices
7.012 Patient and Family Responsibilities
8.001 Electrical Equipment
8.002 Emergency Medical Care Provided to the Public and OSH Staff
8.003 Reporting of Patients on Unauthorized Leave and the…
8.004 Access to Criminal Offender Information
8.005 Access to Tunnel System
8.006 Vehicle Usage Standards
8.007 Employee, Patient and Visitor identification Attachment A
8.007 Employee, Patient and Visitor Identification Attachment B
8.007 Employee, Patient and Visitor Identification
8.008 Transportation of Court-Committed Patients
8.009 Safety Policy
8.010 Hearing Conservation Program
8.011 Safety Committee
8.012 Vehicle Accident Review Board
8.013 Respiratory Protection Policy
8.014 Ward Searches
8.015 Emergency Alarm, Two-Way Radio, and Public Address…
8.016 Employee Response to Violent Situations,Civil and…
8.017 Admission Screenings Safety Plan
8.018 Staff Response to Patient Unauthorized Leave
8.019 Staff Response to Alleged Criminal Acts, Contraband…
8.020 Hazardous Waste Management Program
8.021 Key Inventory and Control Policy
8.022 Fire Alarm Response
8.023 Hospital Parking
8.024 Tool-Sharp Security
8.025 Hazard Communication Program
8.026 Visitors
8.027 Weapons on Campus
8.028 Life Safety Program
8.029 Distribution of Funds for Safety-Related Projects
8.030 Safe Medical Device Reporting
8.031 Personal Protective Equipment
8.032 Access to Patient Care Areas
8.033 Violence Free Workplace, Campus
8.034 Payment of Staff Personal Property Claims
8.035 OSH Duress Alarm System
8.036 Minimizing Violence in Forensic Evaluation Service Attachment 1
8.036 Minimizing Violence in Forensic Evaluation Service
8.038 Medical Emergency (CODE BLUE)
8.039 Use of Restraints for Medical Transfers and Medical Appointments
9.001 Basic Life Support Training (CPR)
9.002 Mandatory Training For All Staff
9.003 Staff Library
9.004 Staff Orientation
9.005 Staff Retreats
9.006 Staff Training in Preventing and Managing Aggressive Behavior
9.007 Uniform Reporting of Continuing Education Credits Earned by Professional Staff
9.008 Staff Training in Health, Safety and Fire Prevention
9.009 Employee Education Development and Training
9.010 Interns
10.001 Research Committee
10.002 Institutional Review Board
B Caution- 6 Core Snapshot
CMO Directive Off Grounds Outings 031612
CMO Directive On and Off Grounds Outings 092311
CMO Directive Safety at Medical Clinic 031912
CMO Directive Special Precautions 071312
DHS-090-010 Transportation of Information Assets