The limited private inpatient facility shall provide services in accordance with the facility service plan submitted to and approved by the Department. A written facility service plan shall include at a minimum: The rationale for the facility including discussion of the organization’s mission, vision, and philosophy for provision of services; The range of services that the facility will provide; The populations to be served, including age groups and other relevant characteristics, and the number of individuals that the program expects to serve; The composition of the facility's governing body, board of directors, or advisory committee, whichever applies; A description of staff or care providers necessary to provide the planned services and any necessary training requirements; The facility’s goals, objectives, and expected outcomes; and A detailed scope or description of services offered. The administrative head of the licensee shall assure that the facility service plan is reviewed by its governing body and updated at least every 3 years. If the licensee makes any changes to its facility service plan, the licensee shall submit its revised facility service plan for the Department’s approval before implementation of the changes.