Where this Chapter specifies that the facility shall develop a policy and procedure, the following standards shall apply.

1. (1) A policy may include a procedure. A procedure may represent policy.

2. (2) Policies and/or procedures developed based on requirements in this Chapter shall identify the following:

   1. (A) The rule or law addressed by the policy and procedure;
   2. (B) The position(s) or personnel responsible for implementation and oversight of the policy and procedure;
   3. (C) The actions to be taken or procedures to be followed by facility personnel. This is the who, what, where, and when of the procedure;
   4. (D) The position(s) or personnel responsible for reviewing the policy and procedure;
   5. (E) A schedule for reviewing the policy that identifies the frequency at which the policy and procedure will be reviewed; and
   6. (F) A signature page to capture the signature and date that the responsible official adopted the policy and/or procedure and the dates that review of the policy and/or procedure were completed.

Added at 36 Ok Reg 1731, eff 9-13-19