(a) The policy and procedure manual shall include at a minimum:
- (1) Detailed job descriptions and duties, by job title, of each employee;
- (2) Policies and procedures for the general administration of the facility and for each department, section, or service of the facility;
- (3) Standards of care;
- (4) Procedures provided by the facility with detailed information of each;
- (5) Orientation practices for new employees;
- (6) Infection control measures;
- (7) Cleaning, disinfecting, and sterilizing procedures;
- (8) Fire safety and other safety and disaster practices;
- (9) Proper routine methods of handling and storing any flammable or explosive agents; and
- (10) Documentation of those personnel who may perform procedures and give patient instruction.
- (b) All policies and procedures shall be reviewed annually and updated if necessary.
- (c) The first page of the manual shall have the current review date and signature of the person conducting the annual review.