minutes of the meeting of the joint ......minutes of the meeting of the joint appropriations page 2...
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MINUTES OF THE MEETING OF THE JOINT APPROPRIATIONS SUBCOMMITTEE FOR INSTITUTIONS WARM SPRINGS AND GALEN February 5, 1981
JACK K. MOORE, Chairman, called the meeting to order at 8:05 a.m., Room 108, Capitol Building. All committee mem-bers were present, except Senator Johnson (excused).
Testimony was given by Peter Blouke, Director of Residen-tial Services; Dr. J. Hamill, Director of Warm Springs State Hospital; Keith Wilson, Business Manager of Warm Springs; Joe Balkovatz, Director of Galen; Dr. S.J. Moffitt, Galen State Hospital; James B. Barkley, Business Manager, Galen State Hospital; Jack Casey, Hospital Administrator; Patrick Mehens, Independent Union; Sheri lee Lund, W.S.R.N. group; Judy Olson, Montana Nurses Association; Doug Booker, Office of Budget and Planning; Ray Hoffman, Fiscal Analyst.
MR. BLOUKE explained Exhibit 80 regarding Warm Springs State Hospital. He stated the problems involved in compiling the information in regard to Warm Springs and Galen and tracking the FTE levels. He asked Mr. Keith Wilson to explain the budget to the Committee.
MR. WILSON explained Contracted Services, page 4. He noted the pathologist service in FY 80 is not reflected in FY 82 and FY 83. On page 6, Dentistry Service is reflected in the 80 base for only three months of the year, that is why the big difference between FY 80 and FY 82.
MR. HOFFMAN explained that Warm Springs contracts with a den-tist and the amounts of $15,655 for FY 82 and $16,921 for FY 83 are reflective of the contract.
MR. WILSON stated on page 8, there is no request for money since the pre-vocational grant expires this year. In Sup-plies and Materials, page 9, the major item was food costs. This was arrived at by the year-to-date per-meal cost of 90.46 ¢ and incremented by inflation. He noted this is where the LFA differs due to different inflation factors.
MR. HOFFMAN stated besides the inflation factor, the Depart-ment is requesting 25.01 FTE more than the LFA recommenda-tions. If the FTE request was granted then this would change the LFA amounts.
MR. WILSON explained on page 10, the Laboratory Supplies were not continued for FY 82 and FY 83. On page 13, he noted the chemicals used for the boiler. He answered REPRESENTATIVE CONROY's question regarding the rock salt by stating it was added to the hard water, and used as a wetting agent. On page 14, under Laundry Supplies there was a change in the fig-ures and for FY 82 the amount should be $15,675 and $16,944
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for FY 83. The reason for the difference in FY 80 and FY 82, is when they consolidated the laundry from Galen and the prison, they received their inventories as well as their work. He noted the figure was arrived at by year-to-date expenditures for FY 81 with applied inflation factors. Linens & Bedding, page 15, also had the year-to-date expenditures from FY 81 applied, plus inflation factors. He explained page 16 regarding the revolving fund, page 17, Title I, page 18, the Pre-Vocational Program which no longer exists, and page 19, the School Lunch, which was put into the general fund this year. He then explained page 20, regarding Com-munications.
REP. ERNST asked about the Leased Line Service. MR. WILSON stated this line was installed at the end of FY 80 and is a line directly into Butte due to the fact that 50% of their STS line calls were to Butte. This would be more efficient and cost effective.
MR. HOFFMAN stated the LFA does agree with this line.
MR. WILSON explained Travel, page 28, regarding in-state lodging for professional purposes. He noted this would be anything not patient-related, and also includes physician-related travel. He stated on page 29, the majority of out-of-state travel was patient-related. He explained when a patient is discharged with no funds, then they are trans-ferred to their horne state.
DR. HAMILL stated Warm Springs gets quite a few transient patients from other states. There is an interstate compact agreement, which involves a patient from another state who receives permission from that state to return, then the trans-portation is paid to return them. He stated if the patient is sick and is being transferred to another hospital, then a staff member must accompany him.
MR. WILSON explained Rent, page 32. He noted a correction be made in the Other Equipment FY 83 amount of $4,664 instead of $5,664.
The CHAIRMAN asked to have page 34, Plumbing maintenance items price increase explained. MR. WILSON stated in FY 80 the inventory was depleted by about $4,000.
REP. CONROY asked about the Tire and Tube cost on page 40 and how many vehicles there were. MR. WILSON stated there were 52 vehicles. They are only 11 vehicles that are over the road, the others are around the grounds. He noted and explained this amount was based on their spending patterns. He stated
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in Other Expenditures, page 45, the majority of the subscrip-tion amount was for the patient library area. He explained the funds to patients, page 46, includes $10 discharge fees for indigent patients, plus a free $5 canteen book monthly for those who are indigent. Under Equipment, page 50, he noted there should be a correction for one sedan rather than two. He noted the 3/4 ton pickup price was arrived at by State Purchasing.
REP. CONROY asked if the fuel for the weed burner, page 53, was appropriated, since this type of burner uses a lot of fuel. MR. WILSON stated he would look into this. He noted on page 54, the air compressor would be used in the receiv-ing hospital area for air circulation. He stated all the Equipment costs are either from State Purchasing or from current catalogues.
MR. HOFFMAN explained that Warm Springs' initial request was $216,667 for FY 82 and $113,397 for FY 83, as compared to the Equipment amounts stated.
The CHAIRMAN asked to discuss the Personal Services area.
MR. WOLCOTT explained some positions are newly created po-sitions from the consolidation, some positions will be de-leted and others would be transferred.
MR. BLOUKE explained there are 33.2 FTE positions, that are broken down into new positions, modified positions, and upgrades. See Exhibit 6A. He noted the LFA has contained all those positions as modified. He noted they have created some direct care positions associated with certain wards, and those are classified as modified positions. He stated they were asking for 25.2 modified positions. He asked Dr. Hamill to explain the method used to allocate direct care staff to the wards.
DR. HAMILL explained the hospital uses the modified Scope formula for direct care nursing staff. On the intake unit, he noted it is best to keep a constant staff of 22 people. He feels this staff number is essential because of the fluc-tuation in the intake population. The intensive unit takes care of the acutely ill short term people, and has a high ratio of 70 direct care nursing people per 100, with an aver-age census of 145. He noted they figure on the formula of 320 patients, whereas the LFA uses 315 patients. Based on this, there would be a four to five FTE difference. If there is an average of 45 people on intensive treatment unit, with a 70 DCNS per 100 patients then this would corne to 31.5 FTE. In the extended treatment, there are studies that
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indicate the old formula was not high enough for staff ratio, because the present patients are a lot sicker than they used to be. The easy ones are transferred to nursing homes. They also admit a lot of new patients into extended treatment, thus a need for a higher staffing ratio. This concern was mentioned to the Governor and he advocated 15 more direct care staff, and they would like to have eight of them in the extended treatment area. One reason for this is the unit runs the cluster program. He noted the forensic area has a high DCNS ratio, because most of the criminally insane, or suicidal patients, are placed here. Because they need help in this area, they have recommended an additional 4.2 FTE. The Spratt building did have one of the lowest staff ratios, because it was mainly used for geriatric patients. Most of the geriatric have been moved to Galen, so what remains in the Spratt building is a wide variety of patients ranging from 22 to 90. They cannot be handled elsewhere, because they are unpredictable assaultive. Pre-release remains constant, however, the children's unit has more incidents of assaultive-ness and running away than the others so needs a higher staff-ing pattern. He explained it is difficult to establish a hard and fast nursing number in anyone unit, because the pa-tients are moved around so much. He noted in the forensic and children's unit, an additional one or two patients means one or two additional staff persons.
MR. BLOUKE stated there is a difference in the definition of direct care between the Department and the LFA. When you cal-culate the staff needed on each ward the ratio is very close, the difference is the LFA feels 243 direct care staff is needed, and the Department feels they need 257. Part of this difference is in the classification of certain positions. He then explained Exhibit SA.
REP. CONROY asked why the transfer of the security from Warm Springs to Galen. MR. CASEY explained the security force currently at Warm Springs are classified as SDA II, which are a direct care classification. In union agreement, the state has agreed not to work people out of their classification. In order to alleviate the potential problem of working out of classification, they have moved the security force down to Galen. The security force presently at Galen is a uniform security force, that does not have any direct care responsi-bility. The Department feels they would get a pure security force at Galen.
REP. CONROY asked what effect this has On their classification, by keeping them out of direct care classification. MR. CASEY stated this has to do with their pay scale. Most of the security people at Warm Springs are Grade 10. The security
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MINUTES OF THE MEETING OF THE JOINT APPROPRIATIONS Page 5 SUBCO~1ITTEE FOR INSTITUTIONS WARM SPRINGS AND GALEN February 5, 1981
force at Galen are currently Grade 9.
MR. BLOUKE stated this was not done as an economic move, this was done more for facilitative coordination between the two facilities. He referred to Exhibit 80, regarding 22.7 dele-tions. He noted when you take all additions, deletions, trans-fers, new positions and modified, the final FTE level is 514.7 and the current FTE level of 514.2 is only a .5 FTE dif-ference. This still makes $94,244 under the current level as a result of the change of positions due to the consolidation.
REP. CONROY asked about the Worker's Compensation problem that developed in the supplemental, how this additional FTE ratio would affect the rates. MR. WILSON stated direct care people are under the Worker's Compensation at a higher premium rate, hopefully with the higher direct care staff, the experience rating for injuries would decrease and would ultimately de-crease the rates. He noted the Worker's Compensation would not reevaluate or reclassify until they have an experience rating to go with.
MR. WOLCOTT stated he feels Worker's Compensation will perform an audit when they reevaluate, and if Warm Springs has over-paid, they will get back a rebate.
MR. WILSON stated the Worker's Compensation do their evalua-tion annually based on premiums paid and benefits paid. So at the end of the year there would be a rebate based on the premiums and benefits. The problem in rates arose when the direct care staff was given a professional rating.
The CHAIRMAN asked to discuss the Galen State Hospital.
MR. BLOUKE stated there is a difference in the FTE level be-tween the LFA and the department because of the calculating and defining of direct care staff. He noted the Operating Ex-penses amounts are very similar.
MR. BARKLEY, Business Manager, explained Exhibit 85, page 3 on Contracted Service. He noted the pharmacist relief amount has not been applied for FY 82 and FY 83, because they now have a second pharmacist. He explained the increase in the Data Processing amounts was due to the SIMS system going into effect in FY 82. He noted all the figures were arrived at on the 80 base. He explained page 4 as those services trans-ferred from Warm Springs, and are shown in the FY 81 column as adjusted- base. In Supplies and Materials, page 5, the food cost is based on an 81 base. He noted in 80 the food cost was 79.4 cents per meal, in 81 the cost was 87 cents.
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The CHAIRMAN stated the base for the Executive for FY 82 is 97.82 cents and FY 83 is $1.06, the LFA base for FY 82 was 96.4 cents and FY 83 was $1.05.
MR. BARKLEY noted the Laboratory amount, page 5, results in the transfer from Warm Springs.
MR. HOFFMAN explained the difference in Supplies and Materials results in a lower FTE level proposed by LFA.
MR. BARKLEY stated on page 8, regarding Rent, there is an ad-dition due to the Data Processing Equipment. He explained the Land rent of 480 acres was due to leasing ground from the State Land Board for irrigation purposes, and in turn renting it back out to a local rancher. This sublease goes directly into the general fund.
MR. HOFFMAN explained the difference in the LFA amounts in Repairs and Maintenance is due to inflationary increases. The Executive granted less inflation in this instance than the LFA.
MR. BARKLEY noted on page 10 there is a transfer of two items from Warm Springs.
SENATOR ETC HART asked how many patients are there currently. DR. MOFFIT stated as of February 3, there were 196 residents. He noted they have a lot of new admissions and transfers to another type of service.
MR. BALKOVATZ stated in the alcoholic center they have an average of 82 and 83 patients, and the capacity is around 75.
SEN. ETCHART asked about the recidivism rate. DR. MOFFIT stated there were approximately two per month which belong in a separate program.
SEN. ETCHART asked about any success ratio figures for these patients. MR. BALKOVATZ stated there are national statistics on rates of recovery on alcohol programs up to 37%, and Mon-tana is right at that average.
MR. BLOUKE stated there is an agreement in the Executive and LFA figures for the Lighthouse Program FTE. He asked Dr. Moffit to explain the Lighthouse Program.
DR. MOFFIT gave a brief overview of the Lighthouse Program. He noted this is related more to chemical dependence than al-cohol, and consists of treatment for not less than six months. These people are screened very carefully, because the maximum
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residents this program can take is 15. He stated Montana is fortunate because there are limited users in the hard drugs. With this specific program, there is a 70% rate of cure, and is one of the best programs in the U.S. He stated the cure rates are elusive, because the difficulty in tracking the residents once they leave.
MR. BLOUKE explained page 19, regarding the alcohol program. He noted there is going to be a new allocation process to determine the indirect and direct costs to the program.
DR. MOFFIT explained the alcohol program, which has a capacity for 75. They are first admitted to the acute care ward and detoxed, then are interviewed by the counselors. Usually within three days, they are ready to be transferred to the in-termediate care, and start the four week program. In some cases there are family programs toward the end, for three or four days. He noted they have picked up some cases with can-cer of the lung, and TB is somewhat on the rise.
The CHAIRMAN stated page 27, modified program, the 1.8 FTE has been included in the LFA amounts, so this can be disre-garded.
MR. BLOUKE then explained Exhibit 81, regarding the addition and deletions and upgrades.
The CHAIRMAN asked if this .5 laundry worker went under Environ-mental Services. MR. BLOUKE stated this specific laundry worker goes under Ancillary Services. He noted the laundry workers at Galen are only involved with sorting and linen.
The CHAIRMAN stated that all laundry will come under Environ-mental Services.
MR. BLOUKE stated there are ten positions that will transfer from Wa~ Springs to Galen, the biggest number are within the business office, and laboratory service, and security. He noted the .5 psychologist from Warm Springs will be a Galen resource person. He stated the major difference with the LFA is in the direct care staff. He asked Mr. Casey to explain the method they arrived at for direct care.
MR. CASEY stated last summer, medical research consultants did a study for SRS, and they received a copy of the report and didn't agree with all areas, so requested Galen to give a management minute study of their own, and a staffing anal-ysis of the current staff. He noted Mr. Hoffman had requested that information, and he gave it to him stating this was un-audited information, and after he did a desk audit on it he
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found it was grossly in error, so it had to be redone. With this latest report the management minutes were calculated. He explained the variety of patients at Galen, and the five patient areas. He stated his study was in agreement with Mr. Lafferty's study based on 185 beds of intermediate care, he read from the report that the review of the needs of the pa-tients reflect a need of nursing staff at a level which is a skilled nursing facility rather than an intermediate care facility. Mr. Lafferty agreed with the present staffing of those five areas in Galen, however, he did not take the sixth floor into consideration during this study. This floor is the acute care floor consisting of 33 beds, and his study came up with 15 FTE needed for that floor. Based on their calculations, they come back to the LFA's recommendation of 79 nursing personnel needed for the intermediate care. Because of medical needs, it is difficult to intertwine those patients, and 67% of the 90 patients studied need skilled nursing, 7% were acute care patients, and the remaining percent were in-termediate care patients. He noted it is·impossible to sep-arate, because on one given floor they have intermediate care, acute care and some skilled care needs. He noted Mr. Lafferty stated there was a possibility of combining two floors, Annex III and Terrell III, this would close down one nurse's station and eliminate five LPN's. He went to Dr. Higgins and asked him his thoughts on this possibility, and Dr. Higgins stated for the mix of population on those two floors, it would be too difficult to combine. He asked Dr. Moffit to explain his opinion of this.
DR. MOFFIT explained the physical plant of Terrell III and Annex III and the distance involved between the nursing sta-tions in the two wings. He feels they would lose their licen-sure, if they tried to have the nursing staff cover both floors. He stated even though this was an intermediate ward, some of the care was acute.
MR. BLOUKE stated what they are asking is a direct care staff-ing of 104.9 based on a population of 107. It is based on the combination of the geography of the building and the mix of the patients in the various units.
The CHAIRMAN asked when they were going to start utilizing the Terrell II floor.
MR. BALKOVATZ stated they would use it when they received au-thority to expand. There was a study for a 48 bed nursing care for veterans, however, the problem that would arise with a veteran contract is that there would not be the ability to mix any other type of patients in the area. This would make it necessary for additional staff.
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~ffi. BLOUKE stated the Department did want to assess the needs of the veterans during the coming biennium, because due to the complications of the consolidation itself it was felt to be inappropriate to try and put together a proposal on this at this time.
The CHAIRMAN asked if there were any problems with the upgrade positions.
MR. HOFFMAN asked how many hours of care would be spent on the intermediate care patient if the staffing proposal by the Department is accepted. MR. CASEY stated overall including the 90 patients/studied, it would allow 5.7 hours of care per patient. Some of these patients are down to less than one hour of care, and others are up to nine and twelve hours of care, so this is the average.
MR. HOFFMAN stated he checked with the Department of SRS, Medical Assistance Bureau, and their figure was 2.53 hours of care provided throughout the state in nursing homes for intermediate and skilled residents.
MR. CASEY stated they have a high patient ratio of the senile, aged patient, and national statistics on psychiatric patients are around 7.7 hours of care per day.
MR. HOFFMAN stated the Committee should be aware the staff did two studies in error, and the third study was finally proposed by the Department. He questions the validity of the staffing as far as the track record is concerned.
MR. CASEY questioned the different ways it was done, and al-though they did it another way they came up with a similar figure to Mr. Lafferty's which is based on intermediate care patients. He stated they are saying that these are not in-termediate care patients, 67% are skilled patients and the majority of these are senile. He noted Mr. Lafferty stated they were staffing Galen adequately.
MR. HOFFMAN stated at one time Galen's licensure was higher than it is now, and about three years ago the licensure was changed more to intermediate beds instead of acute and skilled beds. He felt what the Department was saying now, the licen-sure was grossly in error. He asked Mr. Casey if he would agree with this.
MR. CASEY stated he would have to agree with that after as-sessing the types of care, and they will be taking steps to get this relicensed. He would want to still allocate the same number of beds to the acute care floor and the remaining beds
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of 183 would be allocated between intermediate and skilled. This reallocation would be based on the type of patients at Galen.
MR. BALKOVATZ stated before there were 107 hospital acute beds, and 113 intermediate beds, and it was determined there were too many acute care beds that were not being utilized. The licensure was officially changed on January 7, 1980.
MR. HOFFMAN asked Mr. Casey if the current licensure for Galen State Hospital is 218 (185 intermediate and 33 acute), is the staffing recommendation being proposed by the Depart-ment sufficient to provide that level of care to the 218.
MR. CASEY stated no, because based on the occupancy rate with-in the six areas, if they went on 100% occupancy it would definitely take more staff. The occupancy levels range from 47% to 75% throughout the units. The proposed staffing would accommodate up to 112 overall patients in the acute and intermediate area, excluding the alcohol program and Light-house area.
MR. HOFFMAN asked if the population fluctuates in the units. MR. CASEY stated the population does not fluctuate on all but the acute care floor. On the acute care floor there is approximately 180 admissions per month, and there is a core staff ot take care of the patients on that floor. The acute ward is staffed from 18 to 22 patients.
JUDY OLSEN, Montana Nurses Association, handed out Exhibit 10 and stated the nurses have great concerns over the deletion of the Quality Assurance Program at Warm Springs. She feels the hospital has the right to expect the highest quality of care, and the quality assurance does provide this guarantee. She stated within the Exhibit, they have national guidelines relating to not having a Director of Nursing or a Quality Assurance Program. They also have concerns over the trans-fer of the lab, but with such short notice have not had time to adequately address that issue.
MICHAEL BEAUSOLEIL, Security Officer at Warm Springs, expressed concern over being transferred from Warm Springs to Galen. He does not understand why the security people were not con-sulted in regard to the transfer, he did not feel they were direct care due to their classification. He noted in 1974 they went to the Board of Appeals for an upgrade. He feels the security officers at Warm Springs are more trained than the security officers at Galen. They have had 180 hours of training at the prison, before taking their jobs.
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PATRICK MEHENS, Independent Union at Warm Springs, stated his opposition to the consolidation for Warm Springs at Galen, not the total consolidation itself, but certain aspects in it. He feels the lab is more efficient and cost effective at Warm Springs and better able to meet Medicare and accreditation requirements. If necessary they would be able to produce the figures and information to substantiate this. The Union also opposes the deletion of the staffing service and the pool. This is the most efficient manner in which to meet the con-stantly changing staffing patterns. By giving these adminis-trative duties to the Manager of Treatment Services and Unit Supervisors, you seriously decrease their time for direct patient care. The Union further feels that the consolidation raises serious problems dealing with union contract agree-ments concerning jurisdiction and seniority clauses that have not been adequately addressed by. the Department. In light of these and many other concerns we have, we request that you take a very close look at all the implications inVOlved in consolidation before approving this budget. He stated the Department may discover the cost of the consolidation may be more than the savings anticipated.
ROBERT BETHKE, Lab Technician, Warm Springs, expressed his concern over the proposed consolidation of the clinical lab at Warm Springs and Galen. He felt the central issue pursued is one of economics. It hardly seems economically justified to vacate a physical plant specifically designed for a clinical lab with adequate ventilation, bench space, lighting, elec-trical outlets and safety equipment in preference to two rooms and the addition of two more rooms in need of renovation and remodeling, lacking proper ventilation, lighting, bench space and power sources. The expense of the renovation of the two rooms at Galen State Hospital might be called minimal, but he felt it would be substantial. He felt there was inadequate input from all of the departments of the agencies involved. The analysis of the clinical lab, he felt, is incorrect, as the same rules, formulas and regulations were not used in arriving at a basis to make a just comparison. It was his sug-gestion that the question of consolidation be deferred this biennium and an in-depth study be pursued regarding economic input, immediate agency impact and be recommended to the '83 Legislature.
SHERILEE LUND, R.N. at Warm Springs, expressed concern that the Management of Treatment Service might not be an R.N. At this time there are three R.N.~s in Quality Assurance and they lead several committees in affecting hospital wide functions, and they are primarily over direct care nursing services. She
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is wondering who is going to coordinate these committees. She also expressed concern over the in-service program, and felt the quality would decrease when consolidated with Galen. Another conce~n is the roving security might not be available when needed, because of the past experience with runaways.
There being no further discussion or comments, the meeting was adjourned at 11:30 a.m.
Jack K. Moore, Chairman
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\M Montana Nurses' Association 2001 ELEVENTH AVENUE (406) 442-6"710
P.O. BOX 5718 • HELENA, MONT ANA 59601
February 5, 1981
The Montana Nurses' As.sc::x::.i.ation is OP:fOsErl to the elimination of the Quality l'ssurance
department at Wann Springs State Hospital, arrl urges that thls department not be a
part of the consolidation efforts of the Deparbnent of Institutions except insanuch as
to exterrl the Quality Assurance program to Galen State Hospital. This extension could
be done wit.h the present 7.0 F. T .E. I s in the Q.A. deparbnent.
The .MNA is dedicated to the principle that all citizens of Mont.ana who are also
patients at Wann Springs State Hos-pital or Galen State Hospital have the right to
expect the highest :fOssible quality of health care. Presently, the Q.A. departJnent
seeks to provide this quality health care through the follONing activities:
Monitering of tre..atmetn programs Medical audit utilization review Peer review Credentials review Maintenance of professional standards Policy and procedure monitoring Evaluation of ~issions Inservice Training-Drientation of new anployees Hospital arrl Nursing crnmittees Staff Meetings for professional disciplines 'Iburs
Fragmentation of these services currently provided by the Q.A. departJnent through
assignment of its responsibilities to various units in roth institutions could prove
more costly; resulting in less accountability, urmecessary duplication of effort, and
_inadequate utilization of the expertise arrl experience of present professional staff.
The mechanisn (Q.A.) is nCM in operation, and functioning at a high level to evaluate
the quality of care at Wann Springs; to review treatment prcgrams; and to insure co:n~
pliance with certification, accreditation, and licensure requirements, There is no
goc:d reason to fragment this department as prOfX)sed by the L.F .A.; instead its activities
should be exteIrled to Galen State Hospital.
-
Montana Nul'ses' Association , Page 2
The supervision, evaluation, and ITh:l.intenance of quality care, as well as the aver-all
functioning of staff representing all clinical disciplines, are vi tal responsibilities
which are required legally and for certification and licensure. The National Institute
of Mental Health and Medicare-MErlicaid Guide "Cooo.itions of Participation" state in
part: "Clinical services (nursing services, psychological services, social services,
occupational therapy services) are under the direct supervision of a person represent-
ing that specific clinical discipline who is qualified by education arrl experience for
the position". The present staff in the Q.A. deparbnent meets these recjUirEments and
requlations.
Further I the Joint Ccrmtission on Accredi i::r3.tion of Hospitals Consolidated Stanc1:-Jrds,
1979, adopted the new quality assurance standard for hospitals, to 1:J.
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-
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-I - -~. . -t ... "I
L>:. - -
-
" W
arm
S
pri
ng
s S
tate
Ho
spit
al
Dcscrir>1:~_~ _
__
Qu
anti
ty
Sto
at· in
n W
agon
s (L
arg
est
Av
aila
ble
at
tim
e o
f p
urc
has
e)
1 ea
ch y
ear
$ 9
,00
0 e
acl1
~ S
edan
s -
4 D
oor
-6
Pas
sen
ger
$
7,0
00
eac
:fJ.
Van
3
/4
ton
15
Pas
sen
ger
Win
dow
T
ype
2 1 1
'\
EQ
lJIP
ME
NT
Ju
sti
ficati
on
1976
Ply
mo
uth
Sta
tio
n W
agon
, 7
5,0
00
m
iles
pre
sen
tly
use
d a
s an
ov
er
the
road
veh
icle
; it
is
app
roac
hin
g!
the
tim
e' o
f m
ore
risk
th
an w
e d
esi
re
on
lo
ng
ro
ad tr
ips.
Now
ass
ign
ed
to
th
e
team
ster
po
ol.
1967
Ply
m0
uth
fo
ur
do
or
sed
an,
64,6~8
mil
es;
th
is u
nit
's f
ron
t en
d w
as
wre
cked
se
vera
l y
ears
ag
o,
has
n
ot
bee
n a
tr
ust
ed
ro
ad car
sin
ce,
as
it
do
es n
ot
track
to
o w
ell
. A
ssig
nm
ent
team
ster
po
ol.
1968
Ch
ev
role
t fo
ur
do
or
sed
an,
95
,74
4 m
iles;
th
is u
nit
is
use
d
by
aft
ern
oo
n a
nd
nig
ht
sh
ift
LP
N's
'to
co
mm
ute
bet
wee
n
the F
ore
nsi
c W
ard
s.
Th
is u
nit
wou
ld b
e re
pla
ced
b
y a
h
igh
mil
eag
e AM
C M
atad
or
from
t~e
team
ster
po
ol.
O
ut o
f S
erv
ice -
1 -
Ply
mo
uth
Sed
an
1969
1976
Dod
ge
3/4
to
n 1
5 p
asse
ng
er
van
94
,00
0 m
iles.
M
ain
ten
ance
co
sts
are
ris
ing
on
th
is u
nit
. T
his
u
nit
is
u
sed
o
n o
ver
th
e
road
tr
an
sfe
rs,
recre
ati
on
an
d lo
cal
trip
s.
Out
o
f S
erv
ice 1
D
odge
Van
1
96
5'
Pag
e o
f
FY
82
FY
83
$ 90
00
$ '9
,00
0
$ 7
,00
0
12
,00
0 5()
-
"t
War
m
Sp
rin
gs
Sta
te H
osp
ital
Desc
rip
tio
n
Qua~~ity
1'l
ckU
i)
3/4
to
n,
Cre
w C
ab
(if
sti
ll
av
ail
ab
le a
t th
e
tim
e o
f p
urc
has
e)
Gro
un
ds
Cre
w
Fla
tbed
3
/4 T
on,
Car
pen
ter
Sho
p
Refr
igera
tor,
1
4.3
Cu.
F
t.,
Curren~
Cat
alo
g
(Sea
rs)
Pri
ce
$3
69
.95
FY
82
12
E
ach
@ $
40
6.9
4
FY
83
12
Eac
h @
$4
47
.63
1 1
24
Was
h-in
g M
achi
ne
-C
urr
ent
Cat
. (S
eajr
s)
10
PrI
ce
-$
32
9.9
5
r~
82
5 ea
ch @
$3
63
.94
FY
83
5
each
@ $
39
9.2
3
DrV
l'r
-FY
82
1"Y
83
(Sea
rs)
Pri
ce
@ $
24
9.9
5
5 ea
ch.
@ $
27
4.9
4
5 ea
ch
@ $
30
2.4
3
G.t
:.
Co
nv
ecti
on
o
ven
s M
odel
C
N90
B
FAC
. 1]
0990
GO
Ol,
K
.W.
11
.0,
3 h
ph
.
10 2
, E
QU
IP
ME
NT
Ju
sti
ficati
on
1965
F
ord
3
/4
ton
pic
ku
p,
14
1,2
84
m
iles
A.s
sign
men
t,
Mai
nte
nan
ce M
an
III
1968
Fo
r ~
ton
pic
ku
p w
ith
te
lep
ho
ne
bo
x.
Th
is
tru
ck
has
b
een
very
co
stly
to
main
tain
du
e to
la
rge H
P m
oto
r an
d th
e lo
w
spee
ds
at
wh
ich
ti
me
it h
as b~en
op
era
ted
. F
ou
r clu
tch
rep
lacem
en
ts,
. on
e ne
w fl
y w
hee
l.·
Out
o
f S
erv
ice 1
F
ord
E
con
oli
ne
Pic
ku
p
1963
O
ut o
f S
erv
ice 1
C
hev
role
t 3
/4
ton
Cr~w
Cab
P
ick
up
19
61
$
1955
In
tern
ati
on
al
3/4
T
on F
latb
ed
, $
20
0,0
00
mil
es
body
ru
sted
o
ut,
no
lo
ng
er
fit
fo
r it
s
inte
nd
ed
use
. O
ut o
f S
erv
ice 1
In
tern
ati
on
al
Fla
tbe(
2
Ton
195
6 1
Inte
rnati
on
al
Fla
tbed
3
/4 T
on
1957
Rep
lace
men
t fo
r R
efr
igera
tors
p
urc
has
¢d
$
bet
wee
n 1
955
and
19
77
. O
ld R
efr
iger-
ato
rs a
re b
eyo
nd
re
pair
-
no p
art
s ca
n b
e fo
un
d
to fi
x m
any
old
mo
del
s
Rep
lace
men
t fo
r w
ash
ers
and
d
ryers
in
l $
Pati
en
t L
ivin
g a
reas.
W
ashi
ng m
ach
in
s an
d d
ryers
no
w
in u
se w
ere
pu
rch
ased
b
etw
een
197
0 an
d 1
97
9.
The
st
ack
ty
pe
(dry
heat)
o
ven
s p
re-
sen
tly
in
use
are
o
ld a
nd
cau
sin
g
$
Pa
ge
2
of
T
IT
82
FY
83
7,5
00
7,0
00
4,8
83
$
5,3
72
3,1
90
$
3,5
08
3,7
50
$
3,9
00
£1
-
,
~':a
rm
Sp
rin
gs
Sta
te H
osp
ital
D2
scri
pti
on
Q
uan
tity
liz
SRD
CF.
53
46V
, 20
8AC
, w
p-P
Slg
$
3,7
50
$
3,9
00
.E.
Ove
n,
Mod
el
CN
¢)
Fac
. l4
202G
OO
l,
K.W
. 8
.2,
Cir
. 1
-3 P
h.
)/6
0
cy
cle
s
ang
es,
Ele
c.
, 9
each
ata
log
Pri
ce,
$3
59
.95
Y
82
5 ea
ch
$3
95
.94
Y
83
4 ea
ch
$4
35
.88
ang
es
-G
as
Y 8
2
J ea
ch @
$3
95
.94
Y
83
2 ea
ch @
$4
35
.88
Sears
his
is
a
req
uest
fo
r a
Cass
ett
e
i.de
o T
ape
Rec
ord
er
and
Pla
y-B
ack
':
,;;
Vi:
l (S
un
y
Ih,t
a
Max
w
ith
Ad
apte
rs
o rv
pla
ce
the
ex
isti
ng
re
el-
to-r
ee
yst,,~tn.
1 9 5 1
\
E Q
UI
P M
E 'N
T
Ju
sti
ficati
on
co
nsi
dera
ble
tr
ou
ble
in
bre
akd
ow
ns.
A
lso
, on
hea
vy
ro
ast
ing
day
s w
e do
n
ot
hav
e en
ou
gh
ov
en
spac
e an
d h
ave
bee
n r
ely
ing
on
th
e b
ak
eri
es'
o
ven
s.
Th
at u
hit
is
no
w
bak
ing
fo
r G
alen
S
tate
Ho
spit
al
and
ca
nn
ot
rele
ase
th
eir
o
ven
s to
u
s earl
y
eno
ug
h to
help
u
s o
ut
any
mo
re.
Th
is is
to
re
pla
ce
on
e o
f th
ree st
ack
o
ven
s (l
ow
er u
nit
) th
at
is
co
nti
nu
all
y
cau
sin
g u
s p
rob
lem
s ev
en
tho
ug
h repai~s
are
alm
ost
co
nst
an
t an
d w
ou
ld,
in
co
nju
ncti
on
wit
h
the
two
G.E
. Convect~on
ov
ens,
g
ive
us
the
coo
kin
g p
ower
we
nee
d in
th
e k
itch
en
are
a.
Rep
lace
men
t fo
r ra
ng
es
in P
ati
en
t L
ivin
g a
reas
and
sta
te o
wne
d h
ou
sin
g.
Ran
ges
now
in
use
wer
e p
urc
has
ed
bet
wee
n th
e y
ears
19
58 a
nd
19
77
Old
mo
del
st
ov
es
very
hard
to
fi
nd
p
art
s fo
r an
d
som
e m
od
els
no p
art
s ca
n b
e fo
un
d.
Rep
lace
men
t fo
r ra
ng
es
in P
ati
en
t L
ivin
g a
reas
and
sta
te o
wne
d h
ou
sin
g.
Ran
ges
no
w
in u
se w
ere
pu
rch
ased
betw~en
19
54
an
d 1
98
0.
Part
s an
d
lab
or
on
01
mo
del
st
ov
es
co
st m
ore
than
th
e o
rig
i aI
.,
pu
rch
ase
pri
ce.
1)
The
C
ass
ett
e V
ideo
T
ape
Sy
stem
w
ou
ld m
ake
teach
ing
to
o
pera
te
tap
ing
eq
uip
men
t m
uch
sim
ple
r;
the re
el-
to-
reel
equ
ipm
ent
is,
by
fa
r,
the m
ost
d
iffi
cu
lt p
art
o
f th
e
op
era
tio
n
to ma~ter.
2)
It w
ou
ld
red
uce
th
e p
ossib
ilit
y o
f
..
Pag
e 3
of
7
Fl,
82
F
l 83
$ 2
,75
0
$ 1
,98
0
$ 1
,74
4
$ 1
,88
8
$ 8
72
$ 1
,60
0
5~
-
.. • '.J
ann
Sp
rin
gs
Sta
te H
osp
ital
Des
crip
ti0
1! _
_ ~ _
__
Ql1l!I'l~fu
Har
le
Top
W
ork
Tab
le w
ith
cro
ss
1 b
raced
o
pen
fro
nt
base
. M
aple
to
p
2"
thic
k,
s.s
. tu
bu
lar
bra
cin
g
and
s.
s.
leg
s.
30"
wid
th x
84
" le
I' t
h,
... ,:.
wit
h
5"
dia
. N
.S.F
. sw
ivel
cast
ers
w
ith
lo
ck
s in
lie
u o
f ad
just
ab
le
fe t.
Wh
irlp
oo
l co
mm
erci
al ic
e m
aker
. U
p' to
50
0# p
er
24 h
rs.
l~"
cu
bele
ts
1"
thic
kn
ess
. S
elf
-co
nta
ined
35
0#
sto
rag
e b
in.
Air
co
ole
d
con
den
ser.
H
eavy
d
uty
1 H
.~.
com
pre
sso
r.
115
V S
iilg
le P
has
e,
60
Cy
cle
A.C
.,
14
.0
aver
age
run
nin
g a
mps
. B
aked
ac
ryli
lc
enam
el
cab
inet
fin
ish
in
Go
thic
G
rey.
S
eam
less
po
rcela
in,
enam
eled
fi
nis
h b
in li
ner.
7
3.3
/16
" h
igh
x
48
1/8
"
wid
e x
30"
dee
p.
1
Ho
bar
t 40
3 T
en
deri
zer,
~
HP
Mot
or ~
1 11
SV
, p
lun
ing
co
rd,
6' Satin-poli~
d al
um
inu
m,
cle
ar
pla
sti
c h
ou
sin
g.
1 II
Ht.
lO~
" d
ep
th,
19~
" w
idth
Air
C
om
pre
sso
rs
for
co
ntr
ol
syst
ems
$2
50
2
EQ
uIP
ME
NT
Ju
sti
ficati
on
Th
is is
a
rep
lace
men
t ta
ble
fo
r o
ne
pre
sen
tly
in
use
th
at
ov
er
a p
eri
od
o
f ti
me,
h
as
exp
ose
d a
reas
that
are
n
ot
san
itary
. C
rack
s an
d sp
lits
in
map
le
top
s are
p
rio
rity
fo
r re
pla
cem
ent
in a
cco
rdan
ce w
ith
th
e
sta
te a
nd
co
un
ty h
ealt
h b
oard
s.
We
hav
e o
ne
ice m
ach
ine
that
wo
rks
at
least
part
o
f th
e
tim
e;
the o
ther
is
defu
nct
and
o
ld.
The
mac
hin
e w
e w
aul
lik
e
rep
laced
has
bee
n d
own
for
man
y m
on
ths
now
. T
he
on
e m
ach
ine
that
is
wo
rkin
g a
t cap
acit
y d
oesn
't
sup
ply
u
s w
ith
en
ou
gh
pro
du
ct
in a
cco
rdan
ce
wit
h o
ur
nee
ds.
We
hav
e o
ne
ten
deri
zer
now
in
serv
ice
bu
t d
uri
ng
peri
od
s o
f b
reak
do
wn
we ha~e
no
wh
ere
to
go
to
cub
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eat.
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ur ste
ais
co
me
fro
m
the p
riso
n u
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bed
, an
d w
e do
th
is
two
or
thre
e
tim
es
a w
eek
, d
epen
din
g
on
ou
r m
enus
an
d
the q
uali
t o
f st
eak
mea
t w
e re
ceiv
e.
Th
ese
Air
C
om
pre
sso
rs are
to
re
pla
ce
ex
isti
ng
co
ntr
ol.
C
om
pre
sso
r,
Bld
g.
#2
01
, p
ruv
idin
g
the en
tire
co
ntr
ol
syst
em i
s n
ot
reb
uil
t to
th
e
lon
g-
ran
ge
bu
ild
ing
pro
gra
m.
,
Pa
ge
6
of
7
FY
82
FY
83
$ 3
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$ 1
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0
$ 75
5
$ 25
0 $
25
0
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-
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m Sprin~s
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te H
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h cab
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50
0 F
t.
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/16
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se,,
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rod
s fo
r se
wer
mac
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-$
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00
1
Self
-co
nta
ined
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r co
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r Servic~
2 st
ati
on
s w
ith
su
per
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ater
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just
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c
co
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pro
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Map
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le
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rein
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w
ith
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lled
co
ld ste
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tie r
od~.
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ned
an
d ex
pert
ly s
and
ed a
nd
fi
nis
hed
wit
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ne
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at
of
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two
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ats
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ot
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rced
wit
h
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ti
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lan
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per
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nd
ed
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fi
nis
hed
wit
h o
ne
coat
o~
scale
r an
d
two
co
ats
o
f cle
ar
ho
t la
cqut
:'T'.
1
" E
QU
IP
ME
NT
Ju
sti
ficati
on
Th
ese
mac
hin
es are
in
use
a
gre
at
part
of
the
tim
e,
in c
om
par
iso
n to
o
ther
typ
es
of
are
as.
R
ods
nee
d
rep
lacin
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nd
mac
hin
es
nee
d re
pla
cin
g
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to
th
e cu
t in
sta
ff,
mac
hin
ery
is
m
ore
in d
eman
d.
TIl
e w
ater
co
ole
rs p
rese
ntl
y i
n u
se
on
ou
r se
rvin
g li
nes are
q
uit
e o
ld a
nd
are
co
nst
an
tly
bre
ak
ing
dow
n in
on
e are
a
or
an
oth
er.
E
ith
er
part
s w
eari
n
ou
t o
r le
ak
s fo
rmin
g.
Als
o,
they
h
ave
no
imm
edia
te st
ora
ge a
reas
for
gla
sses,
etc
.
Rep
lace
men
t ta
ble
fo
r p
rese
nt
tab
le
that
isn
't u
p to
sa
nit
ati
on
reg
ula
tio
ns.
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is is
nee
ded
in
ou
r C
en
tral
Kit
chen
are
a a
s ad
dit
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al
pre
para
tio
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pace.
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n a
vari
ety
of
men
u it
ems
are
bein~
pre
pare
d it
cau
ses
peo
ple
cr
ow
din
g e
ajh
o
ther
at
the p
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tab
les
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cre
at
s a
haz
ard
fo
r p
eo
ple
wo
rkin
g w
ith
kn
iv
s an
d o
ther
ute
nsil
s.
Pa
ge
5
of
7
FY
82
FY
83
$ 2
,85
0
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,80
0
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3 '
$ 25
0
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m
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82
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83
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}~
82
FY
83
4
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om
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27
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