PROJECT MANUAL

Project Name:

ABTU WINDOW REPLACEMENT

Project Number:

17-S-45-AWR

Project Address:

Colorado Mental Health Institute – Pueblo

Pueblo, CO

BUILDING 137

Owner:

Colorado Department of Human Services

Date: April 24, 2017

830 N. Main St., Suite 140, Pueblo, CO 81003

TABLE OF CONTENTS 00 01 10 - 1

TABLE OF CONTENTS

Project Owner:

Colorado Department of Human Services

Project Name:

ABTU Window Replacement

Project Number:

17-S-45-AWR

Project Address:

Colorado Mental Health Institute - Pueblo

Building 137

Pueblo, CO

DRAWINGS

Sheets as listed in the “Drawing Index” on sheet G1 of the Set

BIDDING and PROCUREMENT

OSA-Advertisement for Bids

DFM Security Instructions of Contractors

DFM Security Background Information

Bid Bond (SBP-6.14)

DFM HIPAA Confidentiality Statement

CMHIP - POLICY MANUAL

Policy 14.40 – HIPAA – Identifying Protected Health Information (PHI)

Policy 32.00 – Environment of Care – Tobacco-Free Environment

Policy 32.12 – Environment of Care – Security Management – Declaration of Contraband

Policy 32.13 – Environment of Care – Security Management – Searches of Premises, Patients, Staff and Visitors

Policy 32.22 – Environment of Care – Security Management – Employee, Student, Volunteer and

Visitor Identification

Policy 32.23 – Environment of Care – Security Management – Security Access Control

Policy 32.24 – Environment of Care – Building Security

Policy 32.40 – Environment of Care – Hazardous Materials Management – Hazardous Materials

Use and Disposal

Policy 32.52 – Environment of Care – Emergency Management – Emergency Management Plan and Policies for Contractors

Policy 32.60 – Environment of Care – Fire Prevention/Life Safety – Interim Life Safety Measures

Policy 32.81 – Environment of Care – Utility Systems Management – Construction Operations

Policy 32.82 – Environment of Care – Utility Systems Management – Pre-Construction Infection

Control Risk Assessment – Part I

Policy 32.83 – Environment of Care – Utility Systems Management – Pre-Construction Infection

Control Risk Assessment – Part II

TECHNICAL SPECIFICATIONS

DIVISION EIGHT – Openings

08 51 13 Aluminum Windows (IAWs)

08 81 00 Glass Glazing

Rev. 1/28/2013

COLORADO DEPARTMENT OF HUMAN SERVICES

DIVISION OF FACILITIES MANAGEMENT

SOUTHERN DISTRICT

SECURITY

INSTRUCTIONS FOR CONTRACTOR’S

Updated January 28, 2013

1. BACKGROUND CHECK:

A. All Contractors shall submit a typed DFM Background Authorization Form for all employees, within five (5) working days prior to appearance on site

B. Maintain log of workers and visitors to be made available to Owner on request.

2. PARKING:

A. All parking at the Facility shall be in designated parking areas.

B. Restrict entrance of persons and vehicles into Project site and existing facilities on an as needed basis only.

C. All parking lots are State Property. As such, the State reserves the right to search any vehicle parked there, and any vehicle entering or leaving the facilities. This is a warrant less search; the State does not need a warrant to search a vehicle. Workers shall take personal responsibility to search their own vehicles prior to entering facility to ensure no articles therein are declared contraband. Felony violations will be prosecuted.

3. EQUIPMENT AND VEHICLES:

A. Equipment shall be inventoried and accounted for at all times. When a piece of equipment is not in use, it shall be properly secured and stored. A list of equipment stored within the Security Perimeter Area shall be submitted to the Project Manager or his designee for approval. Contractor/Employee vehicles shall have windows rolled up; doors locked and any accessible materials must be secured when parked on State property.

B. The Contractor’s Staging Areas will be designated at the mandatory walk through. All vehicles, tools and equipment will be stored in the designated staging and/or parking areas.

C. All self-propelled equipment to be left on the site will be parked at the designated staging areas and outside the Security Perimeter at the end of each workday. All vehicles and lockable equipment must be secured and locked. At no time is an unattended vehicle to have ignition keys left in the vehicle.

Rev. 1/28/2013 2

4. REPORTING:

A. Each Contractor and all of their employees or sub-contracted employees shall make their presence known to the Project Manager or their designee each and every time they arrive on the job site.

B. Restrict entrance of persons and vehicles into Project site and existing facilities.

C. Allow entrance only to authorized persons with proper identification.

D. The emergency phone number is (719) 546-4911, 4911 or “6” on hospital campus telephone lines.

5. SECURITY RULES AND REGULATIONS:

The following Rules and procedures will apply to all Contractors and their employees working at the Facility.

If the job site is within a Security Perimeter Area actively housing a secured population, the assistance provided has limitations. Contractors are obligated to abide by the rules, regulations, and procedures of the Facility. The rules and regulations of the Facility take precedence if an emergency situation develops.

All rules have been enacted for the purpose of protecting the public and providing a safe and secure environment of care.

These are the two most important rules to remember:

When in doubt, ask an Officer or Project Manager, and the Officer or Project Manager on duty will enforce the rules according to policy.

All Security and Contraband Rules and procedures will apply to all Contractors and their employees working at the Facility.

6. PERSONAL SEARCH;

A. All construction personnel entering a Security Perimeter Area will be required to submit to a personal search, which may be conducted electronically, or “hands on” by the officer on duty. Each employee maybe required to sign a “Consent to Search” form. This form allows a search of any person or any articles in the Contractor’s or worker’s possession to be searched. If there is reason to suspect that a person is attempting to introduce contraband into the facility, that person will be denied access to the facility. Arrest and Criminal Prosecution may result.

B. All Contractor/Employee vehicles, tools, and equipment brought onto State property are subject to search at any time for alcohol and other listed contraband.

7. RESTRICTIONS:

A. No drinking of intoxicants allowed prior to entering State property, no drinking of intoxicants while on State property and no intoxicants will be allowed in any worker’s possession, including their vehicle.

B. Illicit drugs are prohibited. Legal medications, when prescribed by a doctor, must be controlled. Any worker taking prescribed medications must be in the original prescription container and shall contain only the amount for a single day’s dose. Any excess medication may be confiscated.

Rev. 1/28/2013 3

C. No firearms are allowed, even if the holder has a valid concealed weapon’s permit as required by State Statute.

D. No weapons, items that can be readily converted to dangerous weapons or any parts thereof are permitted on State property.

E. No guests are authorized on State property unless properly cleared by the Project Manager. Unauthorized guests will be escorted from the Facility.

F. Cameras are not allowed on site nor photographs taken, except by written approval of Owner in the area of the Work. Photograph taking may be cleared by a DFM Representative only after previously obtaining approval. Judgment will be made by DFM Representative regarding type of escort necessary. The appropriate DFM Representatives to contact for clearance will be Mr. Jim Beach, Mr. Brian Caruso, or Mr.

Greg Trujillo.

G. Mandatory obedience to orders: It is expected that all workers will mandatory follow the orders of the officers on duty. Oftentimes a situation may be developing that an “outsider” does not perceive while an officer will. The “view” of the officer is based upon experience and training and cannot be taken lightly.

H. No activity will be conducted for any inmate or patient that would be in violation of facility rules, i.e. making phone calls, providing cigarettes, money, stamps, etc. Inmates and patients have access to all mail facilities and the phone during specified periods. There is absolutely no reason to take anything in or out of the facility on behalf of an inmate or patient.

8. PROPER IDENTIFICATION:

A. Each worker shall have in his or her possession at all times picture identification (i.e.

driver’s license, or state issued picture ID card).

B. The hours for work within the Security Perimeter will be subject to the approval of the Project Manager or their designee.

9. DECLARATION OF CONTRABAND:

All Security and Contraband Rules and Procedures will apply to all Contractors and their employees working at the Facility.

Under the provisions of Colorado Law, the following items are deemed contraband:

1. Dangerous Instruments (Title 18, Article 2, C.R.S. 1973, as amended)

2. Narcotic Drugs (Title 12, Article 22, Part 4, C.R.S. 1973, as amended)

3. Dangerous Drugs (Title 12, Article 22, Part 4, C.R.S. 1973, as amended)

Pursuant to the authority under the provisions of the Colorado Criminal Code, 18-8-204 C.R.S. 1973, as amended, the following items are declared to be contraband on the institute or agency grounds. No person shall introduce or attempt to introduce these below items into this facility, or on any Colorado State institutional property.

1. Any firearm, explosive device, ammunition, chemical self defense agent, electronic restraint device, knife, or sharpened instrument, bludgeon, projectile device, replica or facsimile of such device, instrument, material, or substance which is capable of causing or inducing fear of bodily injury or death. (It shall be an affirmative defense if the person is a Peace Officer on duty).

2. Any combustible material such as matches or cigarette lighters, unless authorized, or any other substance that is defined in the Hazardous Materials and Waste program (Section A., B., C., and D.)

Rev. 1/28/2013 4

3. Any substance, which is used for the purpose of inhaling or ingesting to produce an intoxicating effect, including nasal inhalers, and paraphernalia, used or identified with the use of drugs and/or narcotics and/or hallucinogens.

4. Any drug or medicine in quantities other than that prescribed and authorized by a Physician, and needed during the term of a visit or stay.

5. Any hypodermic needle, syringe, parts thereof, or any other device than can be used to make injections into the body of human being, unless authorized.

6. Any intoxicating beverage, or ingredients and substances used for brewing or making such beverage.

7. Any key, key pattern, key replica, lock pick, or any other device that could be used to breach the security of the Institution or Divisions thereof, or any secured area or place therein.

8. Any tool or instrument, which could be used to cut, pry, dig, or file, unless authorized.

9. Any chains, rope, ladder, unless authorized.

10. Any counterfeit, forged medium of exchange, or any molds, dies, stamping devices, or any other paraphernalia used, or capable of use to counterfeit or forge said medium of exchange or to defraud the operation of medium of exchange.

11. Any money or coin of United States currency or written instrument of value, unless authorized.

12. Any uncancelled postage stamps or implement of the United States Postal Service, unless authorized.

13. Any written message, item or object that is to be sent or brought to another client (inmate/patient), unless authorized.

14. Any counterfeit or forged identification card.

15. Any mask, wig, disguise, or other means of altering normal physical appearance which could hinder ready identification.

16. Any visual or audio recording device, unless authorized.

17. Any portable two-way communication devices, unless authorized.

18. Any article, item or substance that may be viewed as detrimental or may pose a threat to the safety/security or operations of the Institute/Division Security Management Plans.

19. Examples of Declared Contraband.

a. Incense and Incense Burners.

b. Book Matches.

c. Candles, or gum.

d. Liquid Shoe Polish.

e. Weapons of any kind.

f. Narcotic and Dangerous Drugs.

g. Extension Cords and Multiple Plug-ins.

h. Hotel, motel, or house keys.

I. Drivers License, Credit Cards or Food Stamps.

j. Currency beyond limitations set by Institution.

k. Batteries or battery operated items, except watches, hearing aids, small flat calculator.

l. Fluid Lighters.

m. No fresh cut flowers or potted plants, except directly from florist.

n. No razor with separate blades except for Twin Trac-type disposable and disposable razors, electrical razors are allowed.

o. No douche bags may be taken out or brought in.

p. No crockpots, toasters, broilers, sandwich makers, deep fryers, popcorn poppers or heaters

q. Used 8-track tapes.

r. Radios with police band.

s. Non-dairy creamer.

t. Cameras and Polaroid cartridges.

u. Lottery tickets.

Rev. 1/28/2013 5

10. SECURED FACILITY RULES:

In the event of a disturbance in the facility, all activity will cease until control is re-established.

Contractors and workers will be given specific instructions by the officer on duty. Follow instructions promptly to insure the safety of all persons in the facility.

Each Facility has Emergency Plans that can be implemented at any time to cover any contingencies. Once an Emergency Plan is implemented, it takes precedence over all other activities.

Escape Prevention is the duty and responsibility of all persons in the State of Colorado to prevent escape. (See Colorado Revised Statutes 18-8-201 and 18-8-105.) Escape is deemed to be a continuing activity commencing with the conception of the design to escape and continuing until the escapee is returned to custody or the attempt to escape is thwarted or abandoned. “Assist” includes any activity characterized as “rendering assistance” which is covered in C.R.S. 18-8-105.

Any activity not mentioned herein regarding escape or aiding and abetting are applicable. Simply stated, if any worker becomes aware of or has reason to believe an escape attempt is being planned or is imminent, the obligation to report such information to the proper authorities (any officer) is incurred. Improper handling and storage of equipment such as ladders, ropes, etc. may contribute to escape.

The contractor or designee shall render to the state expert and professional services that meet the standard of quality established by healthcare facilities as provided by the Joint Commission on Accreditation of Healthcare Organizations and in accordance with all state and federal laws and regulations concerning patient confidentiality and in a timely manner consistent with the quality standards of Colorado Mental Health Institute at Pueblo.

Special Note: Any Department of Corrections Facility and Colorado Mental Health Institute at Pueblo

Campus are Tobacco Free Facilities effective June 1, 2008. No tobacco products, including smokeless products, or related paraphernalia such as lighters and matches shall be used, sold or bartered anywhere on the CMHIP campus, and may be possessed only in locked personal vehicles.

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4112 South Knox Court, Denver, CO 80236 P 303.866.7290 F 303.866.7299 www.colorado.gov/cdhs John W. Hickenlooper, Governor | Reggie Bicha, Executive Director

HIPAA CONFIDENTIALITY STATEMENT

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is the policy and practice of Colorado Department of Human Services (CDHS) and the Division of Facilities Management that all patient and/or client information, including the identity of individuals, in CDHS facilities is held in strict confidence. It is also the policy that all visitors, vendors or contractors sign this affidavit indicating agreement with its stipulations.

I agree to maintain the confidentiality of all patient/client information (Protected Health Information PHI), whether in paper, electronic, verbal, or other format, including the identity of any individuals who occupy CDHS facilities. Breach of confidentiality is described as conveying information on any aspect of any patient s treatment or identity, in all settings, to anyone outside the CDHS facility. This includes any patient and/or client by name, address, telephone number or social security number, or any other identifying information. Protected Health Information may not be shared, without the patient s/client s authorization and then only with those having a direct need for such information and as allowed under the CDHS HIPAA Privacy Rule. This is in accordance with the CDHS Policies and Procedures;

Confidentiality of Alcohol and Drug Abuse Records, 42 CFR, Part 2, and the Final CDHS HIPAA Privacy and Security Rules.

I have read this Confidentiality Statement and understand and concur.

Signature Date/Time

Printed Name

Firm Contractor Badge Number

Anthony Gherardini, Interim Office Director Brad Membel, Division Director

Colorado Mental Health Institute at Pueblo POLICY MANUAL

SECTION - HIPAA

POLICY NO. 14.40

Effective Date: 7/9/14

TITLE: IDENTIFYING PROTECTED HEALTH INFORMATION (PHI)

This replaces CMHIP policy 14.40, dated 10/12/11.

I. DEFINITION/PURPOSE

It is the policy of CMHIP to treat as PHI any information that relates to a patient’s health condition, identifies a patient, or for which there is reasonable basis to believe the information can be used to identify the patient and limit the use and disclosure of such information.

The purpose of this policy is to set forth the criteria for determining when information held by CMHIP should be treated as PHI.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy are CMHIP workforce members including, but not limited to full-time employees, part-time employees, trainees, volunteers, contractors, temporary workers, physicians, students, interns and anyone else granted access to sensitive information by CMHIP.

III. PROCEDURE

A. Protected Health Information is designated as any individually identifiable health information, including demographic information collected from a patient, created, received, transmitted or maintained in any form or medium, that:

1. Is created or received by a health care provider, health plan, employer, or health care clearinghouse.

2. Relates to the past, present, or future physical or mental health or condition of a patient and the provision of health care to a patient; or, the past, present, or future payment for the provision of health care to a patient

a. That identifies the patient, or

b. With respect to which there is a reasonable basis to believe the information can be used to identify the patient.

B. PHI means a patient’s personally identifiable health information that is:

1. Transmitted by electronic media

2. Maintained in any medium described in the definition of electronic media

3. Transmitted or maintained in any other form or medium, including paper and fax documents along with oral communications.

IDENTIFYING PROTECTED HEALTH INFORMATION

POLICY NO. 14.40 PAGE 2

C. In the event of a dispute regarding designation of health information, the following persons, respectively, will be responsible for designating health information as Protected Health Information:

1. CMHIP Privacy Liaison (alternate Medical Records Department Director)

2. OBH Compliance Officer

3. CDHS Privacy Officer

D. CMHIP will protect the use and disclosure of a patient’s individually identifiable health information by treating certain identifiers as PHI. The identifiers pertaining to the patient, as well as the patient’s family members, employers or household members and include, but are not limited to:

1. Names

2. Geographic designations smaller than a state, including street address, city, county, precinct, and zip codes (except that the first three digits of the zip code may be used if the area has more than 20,000 residents)

3. All elements of dates (except for year) for dates directly related to a patient, including birth date, admission date, discharge date, date of death, and age (although the year of age may not be used if the age is over 89 unless aggregated into a single category of age 90 or older)

4. Plus those listed in this table:

Telephone numbers Fax numbers Email addresses Social security numbers Medical Records numbers Health plan beneficiary numbers and names Any account numbers Vehicle identifiers, serial numbers and license plate numbers Web Universal Resource Locators (URLs) and Internet Protocol (IP) addresses

Biometric identifiers, such as fingerprints

Full face photographs and any comparable images

Location at CMHIP

Any other unique identifying number, characteristic, or code

E. If individually identifiable health information is “de-identified,” it is no longer treated as PHI.

Birgit M. Fisher, PhD Date Interim Superintendent

SECTION – ENVIRONMENT OF CARE

POLICY NO. 32.00

Effective Date: 10/14/15

TITLE: TOBACCO-FREE ENVIRONMENT

This replaces CMHIP policy 32.00, dated 11/12/14.

PLEASE NOTE: This policy supersedes all hospital, program and department policies referencing tobacco or smoking.

It is the policy of the Colorado Mental Health Institute at Pueblo (CMHIP) to prohibit smoking and the use or sale of any tobacco products on the CMHIP campus.

As a health care facility committed to the health and safety of staff, patients, physicians, visitors, and business associates, CMHIP is taking a leadership role on the major public health issue of tobacco use. To promote CMHIP’s commitment to public health and safety and to reduce the health and safety risks to those served and employed at CMHIP, all CMHIP facilities, campuses, state vehicles, and properties are tobacco-free environments. No smoking of cigarettes, electronic cigarettes (e-cigarettes), cigars, or pipes or use of chewing tobacco in any form or any other tobacco product is permitted in facilities or on properties of CMHIP.

This policy is applicable to all State employees on the CMHIP campus (see map on page 5) whether they are employees of CMHIP or other agencies and includes medical staff, visitors, students, volunteers, vendors, lessees and contractors. This policy is applicable to all inpatients and outpatients.

A ban on tobacco does not take away an individual's rights as there is no “right to smoke” in Colorado. CMHIP does not require staff, patients or visitors to stop using tobacco; however, it is required that people do not smoke or use other tobacco products on this hospital campus or during work time.

The purpose of this policy is to describe how the tobacco-free workplace requirements will be implemented.

DEFINITIONS

Tobacco Products – Cigarettes (including electronic cigarettes [e-cigarettes], personal vaporizers [PVs], electronic nicotine delivery systems [ENDS], pipes, pipe tobacco, tobacco substitutes [e.g., clove cigarettes], chewing tobacco, cigars, dissolvable tobacco products [e.g., orbs (mints)], sticks [toothpicks], strips [product that looks like breath strips, etc.]).

Tobacco Paraphernalia – combustible material is contraband unless authorized (see CMHIP policy 32.12, Declaration of Contraband).

Workplace – CMHIP workplace means facilities or properties including, but not limited to, patient care buildings, clinics, facilities, office buildings, parking lots, CMHIP or State-owned vehicles, or property leased or rented out to other entities. This policy

TOBACCO-FREE ENVIRONMENT POLICY NO.32.00 PAGE 2

applies regardless of whether a CMHIP facility or property is owned and whether or not the other tenants follow similar guidelines. Employees and patients at off-site patient activities shall not use tobacco products.

It is the responsibility of all staff members to enforce the hospital's tobacco-free environment policy by encouraging their colleagues, patients, visitors and others to comply with the policy. Supervisors are responsible for implementing and enforcing CMHIP’s Tobacco-Free Environment policy.

The community, staff, patients and visitors will be informed of the policy through a variety of communication methods.

A. General Policy Provisions

1. No tobacco products, related paraphernalia such as lighters, matches, or products that give the appearance or could be construed as tobacco products by other staff members or patients (e.g., mint chew/snuff) shall be used, sold or bartered anywhere on the CMHIP campus (see map on page 5) and may be stored only in locked personal vehicles.

This restriction also applies to electronic cigarettes (e-cigarettes), personal vaporizers (PV) or electronic nicotine delivery system (ENDS). These devices provide the appearance of smoking and some may have associated health risks and contain detectable levels of carcinogens and toxic chemicals. Currently, there is no scientific evidence that these devices are safe alternatives to smoking.

2. Signs declaring this hospital campus "tobacco free" shall be posted at the hospital campus entrances and other conspicuous places.

3. Hospital employees and other State employees who work on the CMHIP campus will be advised of the provisions of this policy during New Employee Orientation.

4. The hospital will post this policy in employee common areas and in the CMHIP New Employee Orientation Handbook.

5. Tobacco products and paraphernalia are contraband and are not allowed in the buildings on the CMHIP campus. Tobacco products and paraphernalia may be stored only in an employee’s locked personal vehicle. Smoking in personal vehicles on State property is prohibited.

6. Smoking is prohibited in CDHS vehicles.

B. State Employees, Volunteers, Physicians, Students and Contract Workers

1. Respectful enforcement of this policy is the responsibility of all CMHIP employees.

2. State employees, students, medical staff, volunteers, vendors, lessees and contractors are expected to comply with this policy.

3. This policy will be explained to new employees during New Employee Orientation.

TOBACCO-FREE ENVIRONMENT POLICY NO.32.00 PAGE 3

4. Job announcements for all positions on the CMHIP campus will display a notice that CMHIP has a tobacco-free work environment policy.

5. Employees are prohibited from smoking or using other tobacco products during any and all parts of their paid work shift excluding breaks. Employees may not smoke or use other tobacco products in their private vehicles while the vehicle is on CMHIP grounds.

6. Employees who encounter staff or visitors who are violating the tobacco policy are encouraged to politely explain the policy and report the violation to the staff member’s supervisor, if known.

7. Staff who fail to adhere to this policy or supervisors who fail to hold their employees accountable may be subject to progressive discipline culminating in corrective or disciplinary action as defined in CMHIP, Colorado Department of Personnel and Administration (DPA), CDHS Human Resources and Medical Staff policies.

8. During construction, smoking is prohibited in and adjacent to the construction area. A smoking location near the construction area will be designated by the Safety and Risk Manager (SRM) and employees will be advised by the SRM of the approved smoking area. Construction personnel smoking in a non-designated construction area will be removed from the project.

C. Patients

1. Inpatients and outpatients are prohibited from smoking or using any tobacco product or paraphernalia on campus.

2. All patients admitted to CMHIP will be assessed for history of tobacco use and the need for interventions related to tobacco addiction including nicotine replacement and cessation education.

3. Patients may not possess any tobacco-related items on the unit or on the hospital campus except in the patient’s locked personal vehicle.

4. Employees who encounter patients who are violating the tobacco policy are encouraged to politely explain the policy, and report the violation to the patient’s treatment team, if known.

5. Violation of this policy by patients is a treatment issue to be addressed by the treatment team.

6. When a patient is reintegrating into the community and will be followed by Forensic Community-Based Services (FCBS), use of electronic cigarettes (e-cigarettes), personal vaporizers (PV) or electronic nicotine delivery system (ENDS) will be considered for off-campus use only on a case-by-case basis. In such cases, the following applies:

a. The treatment team must submit a request for a policy waiver to Executive Committee (EC) including the clinical rationale for the request.

b. If approved by EC in conjunction with FCBS case management staff, the patient may use the product only during community re-integration activities and may not use them on the CMHIP campus ever.

TOBACCO-FREE ENVIRONMENT POLICY NO.32.00 PAGE 4

D. Visitors

1. Signs are posted at campus entrances and in selected locations inside and outside of the facility.

2. Employees who encounter a visitor who is violating the tobacco policy are encouraged to politely explain the policy to the visitor.

3. Visitors who become agitated or unruly or repeatedly refuse to comply when informed of the tobacco-free campus policy may be reported to the Department of Public Safety (DPS). DPS will respond to the situation as appropriate, according to their professional judgment and need to maintain a safe environment.

E. Outside Groups

Outside groups who use CMHIP facilities for meetings will be advised of this policy.

Violation of the policy will result in the rescinding of approval for the group to meet on this campus.

F. Guidelines for Enforcement Violation Examples

First Offense Second Offense Third Offense Fourth Offense

Smoking outside on property but complies with request to stop

Smoking outside on property and refuses to comply with policy

Smoking in personal vehicle on campus

*Excessive absences from the workplace during assigned shift (extra breaks, longer lunch breaks, etc.)

*Employee’s clothing smells strongly of cigarette smoke

The supervisor must have verifiable reports of the infractions and/or have witnessed the infraction directly.

Verbal intervention with employee.

Review policy and perimeter of the campus, give clear expectation it is not to reoccur. Review the Help Quit education available and possible assistance with nicotine replacement and acupuncture for difficulties with compliance while at work.

The supervisor must have verifiable reports of the infractions and/or have witnessed the infraction directly.

Repeat first offense interventions and document all discussion in a supervisory log.

Refer also to the first verbal intervention and make the expectation clear in writing. Sign the log and have the employee sign that this was reviewed and discussed with them. Again review the assistance available to comply at work.

The supervisor must have verifiable reports of the infractions and/or have witnessed the infraction directly.

Present the employee with a Memorandum of Expectation or a Performance Management Program (PMP) evaluation clearly stating the expectation and consequences if the policy is violated again. Clarify that the behavior will affect the PMP performance rating and may result in further corrective or disciplinary action.

The supervisor must have verifiable reports of the infractions and/or have witnessed the infraction directly.

Document the new infraction and forward with previous documentation to the appointing authority for consideration of an R-6-10 meeting for corrective or disciplinary action that may affect pay, status, or tenure and result in possible termination.

TOBACCO-FREE ENVIRONMENT POLICY NO.32.00 PAGE 5

Staff who witness infractions of any kind are asked to remind the person of the Tobacco Free campus policy. If the offender is a patient, please report the offense to the unit if known. If the offender is staff, please report the offense to the supervisor if known.

*Please refer to related polices, CMHIP Professional Image and Appearance, 30.13 and Nursing Department Manual for Break Procedures

Ron Hale, MBA-HS Date Superintendent

TOBACCO-FREE ENVIRONMENT POLICY NO.32.00 PAGE 6

SECURITY MANAGEMENT

POLICY NO. 32.12

Effective Date: 11/12/14

TILE: DECLARATION OF CONTRABAND

This replaces CMHIP policy 32.12, dated 12/12/12.

It is the policy of the Colorado Mental Health Institute at Pueblo (CMHIP) to ensure a safe treatment environment for patients, staff and visitors.

The purpose of this policy is to describe what is considered contraband on the grounds of CMHIP pursuant to 18-8-203, C.R.S., and 18-8-204, C.R.S. 1973, as amended.

Contraband is defined as any article, item or substance not allowed by law or that may be viewed as detrimental, or that may pose a threat to the safety/security or operation of the Colorado Mental Health Institute at Pueblo.

Nuisance Contraband - Items that are not dangerous, e.g. food items, newspapers, magazines, paper, clothing, etc. (usually found in excess of allowed limits).

The Declaration of Contraband is issued under the authority of the Superintendent, and the Colorado State statutes cited above. Individuals responsible for implementing this policy include all employees, consultants, contractors, students, and volunteers.

The Department of Public Safety (DPS) will investigate violations of this policy.

A. Determination of Contraband

1. The Superintendent, in conjunction with the Security Manager (Chief of the Department of Public Safety) will issue a Declaration of Contraband which lists articles, items or substances that are not allowed on the grounds, such as any article, item or substance that may be viewed as detrimental or may pose a threat to the safety/security or operation of the hospital, and any other article or substance that is not allowed by hospital or program policy.

2. Individuals who have knowledge of violations of this policy will immediately report violation(s) to DPS and complete an Incident Reporting Form, form 1300.

DPS will conduct an investigation of the incident. The results of the investigation will be forwarded to the Superintendent and to the District Attorney’s Office, if applicable.

DECLARATION OF CONTRABAND Policy 32.12 PAGE 2

3. Searches of individuals, packages, and vehicles will be governed by CMHIP policy 32.13, Searches of Premises, Patients, Staff and Visitors.

B. Declaration of Contraband

The following items are deemed contraband by order of the Superintendent. It applies to all patients, staff, visitors, students, volunteers, and anyone who conducts services or business on this campus.

1. Any firearm, explosive device, ammunition, chemical self-defense agent, electronic restraint device, knife, or sharpened instrument, bludgeon, projectile device, replica or facsimile of such device, instrument, material, or substance, which is capable of causing or inducing fear of bodily injury or death.

2. Any combustible material such as matches, cigarette lighters, electronic (vapor) cigarettes, or any other substance that would be considered hazardous to the health and safety of an individual unless authorized, and used in an authorized manner.

3. Any substance used for the purpose of inhaling or ingesting to produce an intoxicating effect, and paraphernalia used or identified with the use of drugs and/or narcotics and/or hallucinogens.

4. Any drug or medicine in quantities other than that prescribed and authorized by a physician, and needed during the term of a visit or stay.

5. Any hypodermic needle, syringe, parts thereof, or any other device that can be used to make injections into the body of a human being, unless authorized; i.e., staff using prescribed medication, such as insulin, are authorized.

6. Any intoxicating beverage, or ingredients and substances used for brewing or making such beverages; perfumes/colognes.

7. Any key, key pattern, key replica, lock pick, or any other device that could be used to breach the security of the CMHIP premises or any secured area or place therein.

Staff and contract personnel are authorized to carry keys or key-related tools for areas designated by Program/Department Directors and/or the Director of Facilities Management. Patients who have home residence on the Advanced Cottage are permitted to have keys to their living quarters on the unit, i.e., exterior doors and their own rooms.

8. Any tool or instrument, or sewing-related device such as scissors, needles, etc., that could be used to stick, cut, pry, dig or file, unless authorized and in an authorized area supervised by staff.

9. Any chain, rope, strap, belt, strip of material or sheeting, noose, ligature, shoelace, plastic bag greater than one (1) quart in size, etc., unless authorized and in an authorized area.

10. Any mop, broom or other cleaning tool on all units unless the patient is formally participating in an IT assignment activity, and is supervised by staff while in possession of the mop, broom or other cleaning tool.

DECLARATION OF CONTRABAND Policy 32.12 PAGE 3

11. Any ladder, unless authorized and in an authorized area.

12. Any counterfeit or forged medium of exchange, or any molds, dies, stamping devices, or any other paraphernalia used, or capable of use to counterfeit or forge a medium of exchange or to defraud the operation of medium of exchange.

13. Any money or coin of United States currency or written instrument of value, unless authorized.

14. Any uncanceled postage stamp or implement of the United States Postal Service, unless authorized.

15. Any written message, item or object that is to be sent or brought to another patient, unless authorized.

16. Any obscene or pornographic or objectionable materials.

17. Any counterfeit or forged identification card.

18. Any mask, wig, disguise, or other means of altering normal physical appearance which could hinder ready identification.

19. Any visual or audio recording device, including but not limited to, camera cell phones, IPads, or personal data assistants (PDAs) in the possession of patients or visitors. (See CMHIP policy 6.60, Photo/Recording Patients.)

20. Any portable two-way communication devices, unless authorized.

21. Any other item in the possession of a patient that is prohibited by another hospital policy (e.g., Seclusion and Restraint), Physician’s Order or unit rules is considered nuisance contraband. Nuisance contraband will not initiate a criminal investigation but will be confiscated.

C. Confiscation of Contraband

CMHIP staff will immediately seize any item determined to be contraband, if safe to do so. In cases where it is not safe for clinical staff to act immediately, clinical staff will notify the DPS officers, who will respond and assist clinical staff, if necessary.

CMHIP police officer(s) will collect and secure any items seized, as appropriate.

SECURITY MANAGEMENT

POLICY NO. 32.13

Effective Date: 11/12/14

TITLE: SEARCHES OF PREMISES, PATIENTS, STAFF AND VISITORS

This replaces policy 32.13, dated 12/12/12.

I. DEFINITION/PURPOSE

It is the policy of Colorado Mental Health Institute at Pueblo (CMHIP) to provide a safe environment for patients, staff and visitors. All individuals and their packages, handbags, vehicles, or other possessions are, therefore, subject to search at any time before being allowed to enter any area of the hospital premises. No one will be permitted to enter the area if, upon Department of Public Safety (DPS) officer or staff request, he/she refuses to allow a search of person, packages, handbag, vehicle or other possessions. The thoroughness of the search is discretionary and will be determined by the nature of the reason for the search and the level of potential risk.

CMHIP respects confidentiality and privacy of patients. Searches will be conducted in a dignified and respectful manner, and in private, when possible. Respect for privacy will not be construed as a right to privacy, however.

The purpose of this policy is to describe when, in the interest of patient, staff and public safety and of further improving security (e.g., the prevention of contraband being introduced into any area, to include patient care and security areas), searches of the premises, staff, visitors and patients are conducted.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include DPS staff, Program Directors, Admissions and unit staff.

III. PROCEDURE

A. Emergency Searches by DPS

DPS will conduct searches of any area, individuals, packages, handbags, vehicles, or other possessions on the grounds of the CMHIP under the following emergent circumstances:

1. There is probable cause to believe that the search will uncover drugs, weapons and/or contraband determined to be dangerous by the Superintendent, or the individual appointed to act for him/her.

2. The Superintendent, or designee, directs the Chief of DPS, or the Command Officer on duty, to conduct the search, and issues a verbal consent to search at that time.

SEARCHES OF PREMISES, PATIENTS, STAFF AND VISITORS

POLICY 32.13 PAGE 2

B. Searches of Patients at Admission to CMHIP

1. An officer from DPS will thoroughly inspect the patient’s property for weapons and other contraband, and conduct a touch search of patients admitted to CMHIP.

The search will be performed at Admissions in either Building 125 or Building 140 by DPS. DPS will also use a handheld metal detection device (“wand”) during this search. The search will be documented on the Admission Summary, Form 190, page 1of the CMHIP Public Safety section by DPS officers in Admissions.

2. Another search and complete inventory of the patient’s property also will be completed by staff on the units.

3. Searches may include the use of a canine(s) trained in the detection of drugs or other items determined to be dangerous.

C. Searches on Patient Care Units

1. Each CMHIP patient care unit and each area frequented by patients (e.g., Recreation Center, Treatment Mall, waiting areas in ancillary departments) will be searched at least once a month. Searches will be randomly scheduled in order to avoid a detectable pattern emerging. The search will be documented on the CMHIP Unit Search Form (form 1301).

2. Unit staff will search the patient’s belongings when the patient arrives on the unit from Admissions. If unit staff find contraband that went undetected during the search performed in Admissions, they will confiscate the contraband per CMHIP policy 32.12, Declaration of Contraband, and complete an Incident Reporting Form, form 1300.

3. Visitors to patient care units are required to leave items that are not brought for patients (e.g., bags, purses, cell phones, etc.), locked in the trunk of their vehicles or in the storage lockers provided on units. Any personal items brought onto patient care units including jackets and coats will be subject to search by either DPS officers or unit staff. Staff will ask visitors to leave coats in storage lockers;

and to empty their pockets if they wear jackets. Unit staff will post notices of these requirements in areas where visitors enter the premises.

4. Unit staff must search any item brought to patients by visitors before the patient is permitted to keep the item and the item must be documented on the Clothing/Property/Medication Record, form 375. Items brought to the patient may not exceed the maximum number or type of items allowed by the unit for that patient. Items currently in possession of the patient may be exchanged for items brought in by visitors and will be documented on the Clothing/Property/Medication Record, form 375. (See CMHIP policy 18.25, Patient Property.)

5. If linen is missing or has been tampered with at the time of exchange, it will trigger a room search and/or a further inspection of patient linens.

POLICY 32.13 PAGE 3

D. Searches of Patient Rooms

1. Staff may search patient rooms at any time on a routine or emergent basis.

Reasons for an emergent search include, but are not limited to:

• suspected or reported possession of contraband

• suspected illicit drugs, alcohol or tobacco use

• concerns for patient safety and security

• missing property

• tampered with/defective equipment

• missing kitchen/dining utensils

2. Patients will not be permitted to remain in the room when the room is searched.

3. At least two staff will be present when conducting a search of a patient’s room.

4. Searching a patient, patient’s room or belongings is considered a clinical intervention; thus, clinical staff will complete the search and may be assisted by DPS officers. Clinical staff will address any concerns patients might have about searches. DPS officers will assume responsibility for handling and documenting any contraband, including fashioned weapons, illicit drugs, alcohol, stolen property or kitchen/dining utensils. Clinical staff are responsible for removing excess property from the patient’s room if the patient has exceeded the allowable amount and documenting on the Clothing/Property/Medication Record, form 375.

(See CMHIP policy 18.25, Patient Property.)

5. If a patient has envelopes, paper bags or packages containing correspondence from his/her attorney, the patient will be required to empty the contents of the envelope, bag or package in front of staff, who will inspect the contents to see that only papers are contained therein, and not items that the patient might wish to hide from staff.

E. Other Searches

1. In general, room searches are completed when a patient is placed on suicide precautions (Levels I and II) and when the patient is placed in seclusion open door restraint, or forensic restriction. Upon completion of the search, if the patient will not be able to return to his/her room, personal property will immediately be secured (refer to CMHIP policy 18.25, Patient Property).

2. When a patient is transferred to a different unit, both the sending and receiving treatment teams will complete a search of patient and his/her property. Any items not permitted on the receiving unit will be removed from the patient’s possession and secured by the sending team. The property record will be amended to reflect which items were sent with the patient and which were placed in appropriate storage (form 375, per CMHIP policy 18.25, Patient Property).

3. Patients re-admitted to CMHIP from outside hospitalization are required to be seen in Admissions before returning to units. The Admission search procedure is carried out for patients returned from outside hospitalization.

POLICY 32.13 PAGE 4

4. A basic search will include at least a pat down of the person by a DPS unit officer, or if DPS is not available, a staff member of the same gender, including checking pockets (staff should wear gloves), removal and inspection of hats or head coverings and shoes, and checking around waist bands and areas of elastic (including stockings and bras) in the clothing being worn at the time. Staff must make efforts to respect the patient’s privacy and dignity at all times while completing such searches.

5. More thorough searches of persons might include the use of a metal detecting wand. A more thorough search of property might include carefully checking inside the item, e.g., radio, battery compartment, etc., or unit staff viewing DVDs or listening to CDs/audiocassettes prior to making them available to the patient.

Staff will take reasonable care not to damage items during searches.

6. In some circumstances, patients might be subject to removal of clothing and placement in a hospital gown or suicide gown.

7. Staff may be subject to a search when DPS determines it to be warranted. At no time may staff or visitors bring cell phones, audio/video recording devices and cameras onto the Hawkins Building units unless authorized to do so.

8. Refer to CMHIP Policy 14.30, Body Cavity Searches for directions should such a search be required.

F. Inspecting Patient Mail and Searching Packages

1. Letters and packages sent to patients must be opened in the presence of staff, who will verify the contents are not contraband. If prohibited items are detected, staff will confiscate the items, and return the items to the sender at the patient’s expense. Refer to CMHIP policy 32.12, Declaration of Contraband.

2. If the items sent in the package causes the patient to exceed the amount of property allowed on the unit, the items may be returned to sender at the patient’s expense, placed with the patient’s other property, or exchanged for other items in the patient’s possession.

3. All mail addressed to Department of Corrections (DOC) patients will be examined for contraband by the DOC mailroom staff at the San Carlos Correctional Facility before delivery to the Hawkins Building. Money and packages will not be delivered to CMHIP and the DOC patients. If an article is returned to sender or not released to the patient, DOC will be responsible for informing the patient as to why mail was withheld (contraband, no return address, etc.).

SECTION - ENVIRONMENT OF CARE -

POLICY NO. 32.22

Effective Date: 12/23/15

TITLE: EMPLOYEE, STUDENT, VOLUNTEER, AND VISITOR IDENTIFICATION

This policy replaces CMHIP policy 32.22, dated 12/12/12.

It is the policy of Colorado Mental Health Institute at Pueblo (CMHIP) to promote safety and security by establishing procedures to identify persons on the CMHIP campus.

The purpose of this policy is to provide the means of identifying CMHIP and Colorado Department of Human Services (CDHS) Southern District employees, students, volunteers, contractors and visitors.

Individuals responsible for implementing this policy include all state employees at

CMHIP.

A. The Department of Public Safety (DPS) will issue all CMHIP and CDHS Southern District employee Proximity (Prox) Identification Badges. All identification badges will display:

1. Employee’s photo

2. Employee’s first and last name

3. Employee's position

B. If a Prox identification badge is misplaced or damaged, the employee is responsible for the replacement cost of $25.00.