(1) The licensee must establish a governing body with responsibility for operating and maintaining the BHIF. The governing body must include the facility's medical director and the facility administrator. The governing body provides organizational guidance and oversight to ensure the provision of safe, effective patient treatment and care to include but not limited to:

(a) adopting, reviewing, and updating as necessary, at least on an annual basis, policies that:

(i) govern the organization and functions of the BHIF;

(ii) provide a process for grievance and conflict resolution for both staff and patients; and

(iii) provide clear lines of authority for administering, managing, and operating the facility.

(b) establishing procedures for recruiting, hiring, and at least annually evaluating the qualified administrator to assure implementation of the facility goals, objectives, and policies and procedures as approved by the governing body;

(c) review all written facility policies and procedures, to ensure they implement all rules and regulations; are current; known to all staff, and available to all staff, patients, law enforcement, or the public; and

(d) approving facility human resource procedures to assure the facility establishes safe hiring and continued employment practices.