# WAC 246-322-035: WAC 246-322-035. Policies and procedures

> Washington · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_035

## Section

- **Citation:** WAC 246-322-035
- **Heading:** WAC 246-322-035. Policies and procedures
- **Jurisdiction:** Washington
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Washington Administrative Code / Title 246 / Chapter 246-322 / Section 246-322-035

## Text

(1) The licensee shall develop and implement the following written policies and procedures consistent with this chapter and services provided:
(a) Criteria for admitting and retaining patients;
(b) Methods for assessing each patient's physical and mental health prior to admission;
(c) Providing or arranging for the care and treatment of patients;
(d) Assuring patient rights according to chapters 71.05 and 71.34 RCW, including posting those rights in a prominent place for the patients to read;
(e) Protecting against abuse and neglect and reporting suspected incidents according to the provisions of chapters 71.05 , 71.34, 74.34 and 26.44 RCW;
(f) Fire and disaster plans, including;
(i) Accessing patient-occupied sleeping rooms, toilet rooms and bathrooms;
(ii) Summoning internal or external resource agencies or persons, such as a poison center, fire department, and police;
(g) Emergency medical care, including:
(i) Physician orders;
(ii) Staff actions in the absence of a physician; and
(iii) Storing and accessing emergency supplies and equipment;
(h) Managing assaultive, self-destructive, or out-of-control behavior, including:
(i) Immediate actions and conduct;
(ii) Use of seclusion and restraints consistent with WAC 246-322-180 and other applicable state standards; and
(iii) Documenting in the clinical record;
(i) Pharmacy and medication services consistent with WAC 246-322-210 ;
(j) Infection control as required by WAC 246-322-100 ;
(k) Staff actions upon:
(i) Patient elopement;
(ii) A serious change in a patient's condition, and immediately notifying family according to chapters 71.05 and 71.34 RCW;
(iii) Accidents or incidents potentially harmful or injurious to patients, and documentation in the clinical record; and
(iv) Patient death;
(l) Smoking on the hospital premises;
(m) Responsibility for patients' personal property, including recording any valuables left on deposit with the hospital;
(n) Allowing patients to work on the premises, according to WAC 246-322-180 ;
s 71.05 and 71.34 RCW;
(iii) Accidents or incidents potentially harmful or injurious to patients, and documentation in the clinical record; and
(iv) Patient death;
(l) Smoking on the hospital premises;
(m) Responsibility for patients' personal property, including recording any valuables left on deposit with the hospital;
(n) Allowing patients to work on the premises, according to WAC 246-322-180 ;
(o) Maintenance and housekeeping functions, including schedules;
(p) Cleaning, inspecting, repairing and calibrating electrical, biomedical and therapeutic equipment, and documenting actions;
(q) Transporting patients for:
(i) Diagnostic or treatment activities;
(ii) Hospital connected business and programs; and
(iii) Medical care services not provided by the hospital;
(r) Transferring patients to other health care facilities or agencies;
(s) Obtaining and retaining criminal history background checks and disclosure statements consistent with WAC 246-322-030 .
(t) Research involving patients;
(u) Clinical records consistent with WAC 246-322-200 , the Uniform Medical Records Act, chapter 70.02 RCW and Title 42 C.F.R., chapter 1, Part 2, 10/1/89;
(v) Food service consistent with chapter 246-215 WAC and WAC 246-322-230 .
(2) The licensee shall review and update the policies and procedures annually or more often as needed.

## Nearby sections

- [WAC 246-322-010 WAC 246-322-010. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_010.md)
- [WAC 246-322-020 WAC 246-322-020. Licensure — Initial, renewal, modifications](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_020.md)
- [WAC 246-322-025 WAC 246-322-025. Responsibilities and rights — Licensee and department](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_025.md)
- [WAC 246-322-030 WAC 246-322-030. Criminal history, disclosure, and background inquiries](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_030.md)
- [WAC 246-322-035 WAC 246-322-035. Policies and procedures](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_035.md)
- [WAC 246-322-040 WAC 246-322-040. Governing body and administration](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_040.md)
- [WAC 246-322-050 WAC 246-322-050. Staff](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_050.md)
- [WAC 246-322-100 WAC 246-322-100. Infection control](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_100.md)
- [WAC 246-322-120 WAC 246-322-120. Physical environment](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_120.md)
- [WAC 246-322-140 WAC 246-322-140. Patient living areas](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_140.md)
- [WAC 246-322-150 WAC 246-322-150. Clinical facilities](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_150.md)
- [WAC 246-322-160 WAC 246-322-160. Bathrooms, toilet rooms and handwashing sinks](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_160.md)
- [WAC 246-322-170 WAC 246-322-170. Patient care services](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_170.md)
- [WAC 246-322-180 WAC 246-322-180. Patient safety and seclusion care](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_180.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_246_322_035. Check the current official text before relying on it. Not legal advice.