(1) Each specialty hospital must have an administrator who:

(a) maintains daily overall responsibility for the facility operations;

(b) develops and oversees the implementation of all policies and procedures pertaining to the operation of the specialty hospital;

(c) establishes written policies and procedures for all facility human resource services;

(d) establishes a process for patient complaints and grievances;

(e) establishes a patient incident report file on all patient incidents or allegation of abuse;

(f) develops and maintains an organizational chart that delineates the current lines of authority, responsibility, and accountability for the administration and provision of all facility patient treatment programs and services; and

(g) develops and implements written orientation and training procedures on all facility policies and procedures for all employees or contractors, relief workers, temporary employees, students, interns, volunteers, and trainees to include, but not limited to:

(i) defining responsibilities, limitations, and supervision of students, interns, and volunteers working for the specialty hospital; and

(ii) verifying each professional staff member's credentials, when hired, and annually thereafter, to ensure the continued credentialing of required licenses.

(2) The administrator must develop policies and procedures for screening, hiring, and assessing staff which include practices that assist the employer in identifying employees that may pose a risk or threat to the health, safety, or welfare of any resident and provide written documentation of findings and the outcome in the employees file.

(3) In the absence of the administrator, a staff member must be designated to oversee the operation of the facility during the administrator's absence. The administrator or designee must be in charge, on call, and physically available on a daily basis as needed, and must ensure there are sufficient, qualified staff so that the care, health, safety, and welfare needs of the patient are met at all times.

(4) If the administrator is absent for more than 30 calendar days, the department must be given written notice of the individual who has been appointed as the designee.