SECTION 310:670-1-5. Policies and procedures

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

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

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

(A)   The rule or law addressed by the policy and procedure;

(B)   The position(s) or personnel responsible for implementation and oversight of the policy and procedure;

(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;

(D)   The position(s) or personnel responsible for reviewing the policy and procedure;

(E)   A schedule for reviewing the policy that identifies the frequency at which the policy and procedure will be reviewed; and

(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.

[Source: Added at 36 Ok Reg 1731, eff 9-13-19]