(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The policies and procedures shall include but not be limited to:

(c) The responsibility and the accountability of the psychiatric rehabilitative activities service to the medical staff and administration shall be defined.

(d) Patients shall be evaluated and a treatment program shall be established and modified with the concurrence of the referring physician.

(e) Signed progress notes shall be entered into the patient's medical record by the therapist at least weekly. A summary note shall be written upon completion of the treatment program.

(f) Meetings and conferences with other members of the mental health team shall be held in order to plan, review and coordinate patient treatment programs.

(g) There shall be regularly scheduled in-service training for all levels of staff.

(h) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.