4. The board of directors of every institution operating a rehabilitation centre must adopt a protocol for placement in an intensive supervision unit in its facilities in accordance with this Regulation.
The protocol must contain
(1) a statement of the legal framework;
(2) the guidelines and clinical and administrative processes; and
(3) the required and recognized clinical tools, including the intensive supervision program orientation profile.
The executive director of the institution or the person the executive director authorizes must ensure that the protocol is complied with.