Tag Archives: hopsital

Colorado Mental Health Institute At Pueblo Policies And Procedures

This is the second installment of Colorado Mental Health Institutes’ Policies and Procedures.  This time CMHIP Pueblo’s policies and procedures are given.

Here are CMHIP at Fort Logan’s policies and procedures.

The reason behind this article is because the Colorado state government is horrible at providing public records online.  A quick look at the Colorado Mental Health Institute at Pueblo website only provides a cursory overview of what the state mental hospital does.  Unfortunately, most of that information does not help friends and families, nor the public understand how the hospital operates.  I have seen first-hand how a person with mental health issues, can be detained and transferred to another facility, leaving the family feeling powerless and victimized.  For family and friends, a better understanding of the policies and procedures allows them not only to understand what is happening but also to communicate with hospital staff. The community also benefits from the availability of the policies and procedures by acting more effectively as watchdogs and ensuring some of the most vulnerable members of society are not taken advantage of or abused.      To better understand the operations, I filed a public records request for the policies and procedures.

Before we jump in to the policies and procedures, a little background information is useful.  CMHIP Pueblo is different from its sister hospital in Fort Logan, in that Pueblo serves civil clients but also individuals from the criminal justice system.  Individuals in the criminal justice system who are adjudicated not guilty by reason of insanity or  incompetent to proceed are treated at CMHIP Pueblo.  Furthermore, the hospital provides court ordered evaluations for defendants in the criminal justice system.  The bed capacity is 451, approximately, 4.5x what Fort Logan can handle.

Here are links to each policy section and I will highlight some of the interesting policies in each section (there are many more policies than the ones I highlighted, I just chose the ones I found interesting).

Section 1 – Clinical Risk Management

  •  Policy 1.05 details Plan of Care
  •  Policy 1.27 details Discipline Auditing of Assessments Progress
  •  Policy 1.28 details Active Treatment and General Activities
  •  Policy 1.53 details Patient Privilege Levels
  •  Policy 1.54 details GPS Patient Monitoring
  •  Policy 1.65 details Not Guilty By Reason of Insanity and Incompetent to Proceed Disposition Committee

Section 3 – Medication / Treatment

  • Policy 3.01 details Medication Practices
  • Policy 3.05 details Pain Management
  • Policy 3.08 details Assessment for Psychiatric Patients
  • Policy 3.25 details Diagnosis Reporting
  • Policy 3.38 details Root Cause Analysis  and Sentinel Event Investigation (a sentinel event is an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”)

Section 6 – Clinical Risk Management

  •  Policy 6.05 details Intractable Injurious Behavior Protocol (intractable injurious behavior is “chronic, dangerous behaviors safely” where a use of restraint or force is used to deescalate the situation”)
  •  Policy 6.20 details Electroconvulsive Therapy (electroconvulsive therapy is “is a procedure in which electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses,” according to the Mayo Clinic.  CMHI at Pueblo did not define it in their policy.)
  •  Policy 6.25 details Involuntary Psychiatric Medications
  •  Policy 6.30 details Consent for Special Therapies
  •  Policy 6.38 details Clinical Employee Use of Force and Self Defense
  •  Policy 6.42 details Use of Safety Smock or Blanket
  •  Policy 6.45 details Locked Door Seclusion and Open Door Restraints Medical Protective Restraints
  •  Policy 6.60 details Photo Recording Patients

Section 8 – Assessments

  •  Policy 8.15 details Involuntary Laboratory Studies
  •  Policy 8.25 details Medical Education
  •  Policy 8.51 details Care of the Dying Patient
  •  Policy 8.57 details Sexual Assault Allegations and Examinations
  •  Policy 8.60 details Code Zero (Code Zero is the “procedure is to provide basic life support until ambulance paramedics arrive to stabilize and transport the victim to the appropriate treatment area or facility”)

Section 10 – Admissions

  •  Policy 10.00 details Admissions
  •  Policy 10.23 details Admission Care and Transfer Process of Individuals with Intellectual Disabilities

Section 12 – Medical Records

  •  Policy 12.01 details Medical Record Chart Organization
  •  Policy 12.10 details Abbreviations and Symbols

Section 14 – Legal / Consent

  •  Policy 14.10 details Subpoenas
  •  Policy 14.15 details Duty to Warn and Protect
  •  Policy 14.30 details Body Cavity Searches
  •  Policy 14.41 details Privacy Rights of Patients
  •  Policy 14.56 details Personal Representatives
  •  Policy 14.66 details Research Guidance for Potential Researchers
  •  Policy 14.82 details HIPAA Safeguards

Section 15 – HIPAA Security

Section 16 – Patient Rights

  •  Policy 16.10 details Organization Ethics
  •  Policy 16.11 details Unanticipated Outcomes
  •  Policy 16.50 details Patient Rights
  •  Policy 16.51 details Patient Right to Representation by an Attorney

Section 18 – Patient Services

Section 22 – Department of Public Safety

Section 24 – Administration

  •  Policy 24.12 details Pharmaceutical Company Representative Access to CMHIP Patient Care Areas
  •  Policy 24.13 details Tours of CMHIP
  •  Policy 24.55 details Interstate Transfers

Section 26 – Finance

Section 28 – Information Management

Section 30 – Management of Human Resources

  •  Policy 30.12 details Conflicts of Interest
  •  Policy 30.56 details Disclosure of Criminal Charges
  •  Policy 30.61 details Staff Competency

Section 32 – Environment of Care

  • Policy 32.02 details Incident Reporting
  • Policy 32.04 details Preventing Needlestick and Sharps Injury
  • Policy 32.10 details Escapes and Reporting Unauthorized Absenses
  • Policy 32.13 details Searches of Premises Staff, Patients and Visitors
  • Policy 32.14 details Knife Utensil Flatware Accountability
  • Policy 32.24 details Building Security
  • Policy 32.26 details Civil Disturbance Riot
  • Policy 32.35 details Hostage Situations
  • Policy 32.37 details Reporting Accidents Occurring to the Public