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(a) A facility must have a policy and procedures manual that is approved by the governing board. The governing board shall review the manual annually and revise the manual as necessary. If a facility has an advisory body as defined in 7 AAC 13.030(b) , adoption, review, and revision of the manual must be based upon recommendations of the advisory board.
(b) Provisions in the policy and procedures manual must be internally consistent and consistent with regulations of the department.
(c) A facility shall maintain written policies and procedures in the following areas:
(1) fiscal administration, including provisions required under 7 AAC 13.075;
(2) personnel administration, including provisions required under 7 AAC 13.080;
(3) evaluation and research, including the provisions of 7 AAC 13.085;
(4) quality assurance and utilization review, including the provisions of 7 AAC 13.090;
(5) service delivery to the physically handicapped, including the provisions of 7 AAC 13.100;
(6) serving major language and cultural population subgroups, including the provisions of 7 AAC 13.100;
(7) 24-hour availability of emergency services according to 7 AAC 13.100;
(8) ensuring coordination and continuity of services to clients, including the provisions of 7 AAC 13.105;
(9) ensuring privacy in facilities, including the provisions of 7 AAC 13.110;
(10) patient records, including the provisions of 7 AAC 13.115 - 7 AAC 13.120;
(11) rights of patients, including the provisions of 7 AAC 13.130 - 7 AAC 13.135;
(12) a plan for management of pharmaceuticals stored in the facility; and
(13) a plan for procurement and inventory management.
History: Eff. 3/17/85, Register 93
Authority: AS 18.25.100
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Last modified 7/05/2006