CENTRAL STATE HOSPITAL POLICY SUBJECT: MAIL SERVICE/USE OF INTER-OFFICE/INTER-DEPARTMENTAL CORRESPONDENCE AND URGENT MEDICAL INFO ENVELOPES

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1 Page 1 of 5 CENTRAL STATE HOSPITAL POLICY SUBJECT: MAIL SERVICE/USE OF INTER-OFFICE/INTER-DEPARTMENTAL CORRESPONDENCE AND URGENT MEDICAL INFO ENVELOPES ANNUAL REVIEW MONTH: RESPONSIBLE FOR REVIEW: September Materials Management LAST REVISION DATE: September 2010 I. GENERAL The purpose of this policy is to ensure that efficient and timely mail service is provided to all organizations, individuals, and to staff members residing in certain state housing units located on the hospital grounds. II. INDIVIDUAL MAIL A. Individuals have the right to communicate by mail in accordance with the provisions of the Official Code of Georgia Annotated, Sections , and B. Individuals who do not have sufficient funds for postage may mail two (2) letters each week at hospital expense. The building cashier is responsible for coordinating with the Cashier's Office to determine that individuals sending mail at hospital expense do not have sufficient funds on deposit for postage and that these individuals are limited to two (2) letters each week at hospital expense. The living unit supervisor will ensure that correspondence is properly and legibly addressed and contains a return address (which is not identifiable as a hospital address). C. Each individual shall be allowed to receive, send and mail sealed, unopened correspondence and no individual s correspondence shall be opened, delayed, held or censored by the facility, except under the following conditions: (i) (ii) If there are reasonable grounds to believe that incoming mail contains items or substances which may be dangerous to the individual or others, the chief medical officer may direct reasonable examination of such mail and disposition of items or substances found therein. All writings must be presented to the individual within 24 hours of inspection. The chief medical officer may apply to the court for a temporary order to

2 (iii) (iv) (v) (vi) Page 2 of 5 restrict outgoing mail. The court, upon a showing of probable cause that such mail is dangerous to the individual or others, may grant a temporary restriction of the individual s mail privileges, provided that within 5 days after the issuance of such temporary order, the court holds a hearing to determine whether or not an order of restriction for an extended time shall issue. In no event shall mail be restricted pursuant to such temporary order for more than 5 days. If the court determines at the hearing that the individual s outgoing mail is dangerous to the individual or others, it may order the mail restricted for a period not5 to exceed 30 days. The court order for restriction of mail for an extended period may be renewed as necessary for periods not to exceed 30 days with a new hearing to take place each time. The chief medical officer of the facility shall restrict communication as provided in the court order. (vii) Any restriction of incoming or outgoing mail under Section (4) (a) shall not exceed a period of 5 days, except that such restriction may be renewed by the chief medical officer for a period not to exceed 5 days, provided that such renewal periods in the aggregate shall not exceed the period specified in the court order when outgoing mail is restricted pursuant to such order. Prior to a renewal, the chief medical officer shall make a new determination that such mail continues to be dangerous to the individual or others. (viii) Each time that an individual s incoming or outgoing mail is examined, written notice of the examination, and notice of the right to a full and fair hearing within 5 days after a temporary court order, shall be served on the individual and his/her representatives as provided in Section A voluntary individual may waive in writing such notice to his representatives. In addition, the circumstances surrounding the examination of any mail shall be recorded in the individual s clinical record. D. A Critical Incident Report is to be completed in all cases when therapeutic indications necessitate restrictions. E. Correspondence of the individual with his/her attorney shall not be restricted under Section (4) (a), nor shall correspondence to an individual from a public official be restricted under this section.

3 Page 3 of 5 III. INCORRECT OR ILLEGIBLE ADDRESSED MAIL All mail incorrectly or illegibly addressed will be returned to the sender, provided the return address is legible. In the event both address and return address are illegible, mail will be delivered to the local U.S. Post Office for appropriate handling. IV. CERTIFIED, REGEISTERED OR SIGNATURE REQUIRED MAIL Incoming mail that is received by the Central State Hospital Mail Services Department, addressed to individuals and/or staff and has been sent as certified, registered or signature required shall be handled in the following manner: A. Individual mail shall be hand-delivered by the mail services carrier to the resident living unit of the individual. The delivery shall be made to the living unit service director s office to obtain signature. Signatures may be obtained from the living unit service director, nurse supervisor, social services provider or other staff member authorized by the service director. B. Mail designated for non-individual care services, departments or offices shall be delivered to the service chief, department head or office director to obtain signatures. V. INTER-OFFICE MAIL - "Inter-Office Correspondence" Envelopes (pink) "Inter-Departmental Correspondence" Envelopes (brown) Inter-office mail, which is intended for official hospital business only, will be addressed with the name of the individual or organization and building. Routine inter-office mail is usually forwarded in the Central State Hospital inter-office correspondence envelope (pink) or interdepartmental correspondence envelope (brown). Inter-office mail that cannot be delivered because of an inadequate, incorrect or illegible address will be delivered to the Facility Support Services Director for disposition. VI. INTER-OFFICE MAIL - Medical Reports - "Urgent Medical Info" Envelopes (green) Medical reports generated by the CSH laboratory and other diagnostic services require prompt processing and delivery to the individuals' direct care living areas. Therefore, the hospital provides a green envelope only for use by these services and this mail is to be given priority by all employees. Each Service Chief is responsible for developing an internal policy to assure the prompt processing and delivery of the green envelope. A. The Clinical Director for diagnostic services will assure that the following steps are taken in processing medical documents for delivery to the individual s parent service

4 Page 4 of 5 area. 1. The following medical documents will be placed in a green envelope addressed to the individuals' parent living area and building in which the unit is located. a. Radiology results. b. Clinical Laboratory & Pathology results. c. Typed Narrative Summaries. d. Other diagnostic test results such as EKG's, Respiratory Therapy, and EEG s. 2. The green envelopes will be placed in a location in the Culver Kidd Building where they may be picked up twice each day by the CSH Dispatch/Motor Transport personnel. (Exact location to be provided to the Dispatch Office.) B. The Facility Support Services Director will assure that: 1. Green envelopes are given priority in delivery by CSH Dispatch/Motor Transport personnel. 2. CSH Dispatch/Motor Transport personnel will pick up green envelopes in the Culver Kidd Building once each morning and once each afternoon. 3. Green envelopes are returned by Mail Distribution Center employees to the appropriate Service Chief if placed in the CSH mail or for hand delivery in a service area other than the Culver Kidd Building. 4. Green envelopes are delivered promptly to the appropriate locations within each building as designated for CSH mail. C. Service Chiefs will assure that: 1. The Facility Support Services Director is provided a list of current locations where mail is picked up and delivered in each building. 2. An internal system is developed to assure that the green envelopes are promptly delivered to the appropriate individual care area within each service. 3. At least weekly, green envelopes are returned in an Inter-Departmental Correspondence (brown) envelope to the Culver Kidd Building. Only Culver Kidd Building staff will use the green envelope for mailing purposes. VII. EMPLOYEE MAIL

5 Page 5 of 5 A. Mail delivery service will not be furnished to residences of employees by Central State Hospital. Employees residing in state housing who do not have U.S. Mail service are eligible for lock type mailboxes in the CSH Mail and Distribution Center. B. Effective January 1, 2008, CSH employees who reside in state housing and utilize a mail box in the CSH Mail and Distribution Center will be required to pay a nonrefundable annual charge of $ Employees who obtain state housing after January 1 who wish to subscribe to this service will be assessed at a rate of $5.00 per quarter or portion thereof. This fee shall be paid at the CSH Cashier s office located in the Lawrence Building. The annual fee must be paid by January 31 of each year or the service will be discontinued. C. Employees, other than those residing in state housing, shall not use CSH as an address for receiving personal mail. Personal mail addressed to employees not residing in state housing will be returned to sender. All employees are responsible for notifying their correspondents of their correct mailing address, including ZIP CODE number. VIII. STAFF RESPONSIBILITY FOR MAIL A. Personnel who are responsible for preparing out-going hospital mail shall be familiar with the classification of mail and, before sending to the mail room, will indicate on envelopes or packages if the items are to be mailed by other than the first class method. The most economical means will be used except in those cases when the contents and/or priorities warrant special consideration. B. The Facility Support Services Director is responsible for monitoring mail received or dispatched through the CSH Mail and Distribution Center to ensure compliance with this policy. C. All employees completing the addressee section on the Inter-Office/Inter- Departmental Mail envelopes will use one line only per addressee to ensure the most economical use of hospital purchased envelopes. Inter-Office correspondence envelopes are not to be sealed, but simply have the flap folded into the inside of the envelope. Approved: This policy has been approved by the RHA and CMO.