The governing body, through the chief executive officer, shall ensure that personnel policies and practices which adequately support sound patient care are established and maintained. The policies shall be reduced to writing and made available to all employes, and they shall be reviewed periodically, but no less often than once every two years. The date of the most recent review shall be indicated on the written policies. A procedure shall be established for notifying employes of changes in the established personnel policies.
28 Pa. Code § 103.34