(1) The licensee shall develop and implement the following written policies and procedures consistent with this chapter and services provided:

(a) Criteria for admitting and retaining patients;

(b) Methods for assessing each patient's physical and mental health prior to admission;

(c) Providing or arranging for the care and treatment of patients;

(d) Assuring patient rights according to chapters 71.05 and 71.34 RCW, including posting those rights in a prominent place for the patients to read;

(e) Protecting against abuse and neglect and reporting suspected incidents according to the provisions of chapters 71.05, 71.34, 74.34 and 26.44 RCW;

(f) Fire and disaster plans, including:

(i) Accessing patient-occupied sleeping rooms, toilet rooms and bathrooms;

(ii) Summoning internal or external resource agencies or persons, such as a poison center, fire department, and police;

(g) Emergency medical care, including:

(i) Physician orders;

(ii) Staff actions in the absence of a physician; and

(iii) Storing and accessing emergency supplies and equipment;

(h) Managing assaultive, self-destructive, or out-of-control behavior, including:

(i) Immediate actions and conduct; and

(ii) Documenting in the clinical record;

(i) Pharmacy and medication services consistent with WAC 246-324-210;

(j) Infection control as required by WAC 246-324-100;

(k) Staff actions upon:

(i) Patient elopement;

(ii) A serious change in a patient's condition, and immediately notifying family according to chapters 71.05 and 71.34 RCW;

(iii) Accidents or incidents potentially harmful or injurious to patients, and documentation in the clinical record; and

(iv) Patient death;

(l) Smoking on the hospital premises;

(m) Responsibility for patients' personal property, including recording any valuables left on deposit with the hospital;

(n) Allowing patients to work on the premises, according to WAC 246-324-180;

(o) Maintenance and housekeeping functions, including schedules;

(p) Cleaning, inspecting, repairing and calibrating electrical, biomedical and therapeutic equipment, and documenting actions;

(q) Transporting patients for:

(i) Diagnostic or treatment activities;

(ii) Hospital connected business and programs; and

(iii) Medical care services not provided by the hospital;

(r) Transferring patients to other health care facilities or agencies;

(s) Obtaining and retaining criminal history background checks and disclosure statements consistent with WAC 246-324-030;

(t) Research involving patients;

(u) Clinical records consistent with WAC 246-324-200, the Uniform Medical Records Act, chapter 70.02 RCW and Title 42 C.F.R., chapter 1, Part 2, 10/1/89;

(v) Food service consistent with chapter 246-215 WAC and WAC 246-324-230.

(2) The licensee shall review and update the policies and procedures annually or more often as needed.