For juvenile facilities with on-site health care staff, the health administrator, in cooperation with the facility administrator, shall develop, implement and maintain a facility-specific health services manual of written policies and procedures that address, at a minimum, all health care related standards that are applicable to the facility.

Health care policy and procedure manuals shall be available to all health care staff, to the facility administrator, the facility manager, and other individuals as appropriate to ensure effective service delivery.

Each policy and procedure for the health care delivery system shall be reviewed at least every two years and revised as necessary under the direction of the health administrator. The health administrator shall develop a system to document that this review occurs. The facility administrator, facility manager, health administrator and responsible physician shall designate their approval by signing the manual.