Policies and Procedures. A licensee shall ensure that all policies and procedures affecting the scope of activities performed in the laboratory are: Documented; and Communicated to, understood by, available to, and implemented by employees performing the activities. A licensee shall ensure that: Documents issued to employees are reviewed and approved for use by authorized employees before issue; The current revision status and distribution of documents is established to preclude use of archived documents; Authorized documents are available at all locations where casework is performed; Archived documents are promptly removed from access or otherwise identified to ensure against unintended use; Documents are uniquely identified, including date of issue or version, page numbering, total number of pages or a mark to signify the end of the document, and the issuing authority; Changes to documents are approved by the same authority that issued the document and altered or new text is clearly identified; and Documents in computerized systems have equivalent procedures. A licensee shall develop, establish, maintain, implement, and require that technical procedures meet the following: The procedures included are: Generally accepted in the appropriate forensic field or supported by data gathered and recorded in a scientific manner; Available to all appropriate employees; Able to produce valid and accurate results; and Reviewed annually by the director or the director’s designee and this review shall be documented; All procedures include, at a minimum: Sample or specimen preparation, as needed for the method; Required quality control, standard, and reference material; Calibration requirements and instructions; Interfering substances and potential sources of error; Literature references; Special analytical and safety precautions; Step-by-step instructions; and Calculations, if required; The laboratory has a document control procedure to determine when the technical procedure has been discontinued or retired. A laboratory procedure identifies which documents are to be maintained in the case file; All changes to a procedure are approved and signed by the director; The SOPM is available to all forensic analysts and examiners; A departure from the SOPM is: Approved by the laboratory director or qualified designee before implementation; Scientifically validated before implementation; Written; and Communicated to the quality assurance manager; The laboratory has a procedure for determining the reasons, criteria, or conditions for when a report is not produced; The laboratory has a procedure or policy for technical review of reports that: Defines criteria for the technical review, for example, number or percent of case reports reviewed or corrective action protocol if discrepancies are found; Ensures that a review cannot be performed by the examiner or analyst who prepared the report; and Ensures that a technical review of a one-individual unit is performed at a review percentage determined by the laboratory director by an analyst or examiner of another licensed forensic laboratory, who is qualified within the same disciplines or subdisciplines; and The laboratory has a procedure for administrative review that: Requires that reviews be performed on all case reports; Specifies who may perform the administrative review; Clearly defines how the administrative review is documented; and Requires that reviews be performed before case reports are issued. A licensee shall ensure that the laboratory has a policy and procedure for the handling of written or oral complaints received from customers, laboratory employees, or other parties. Postmortem Forensic Toxicology. In addition to applicable sections of this regulation, a laboratory performing postmortem forensic toxicology shall have: A record of sample signatures and initials of all employees handling specimens and performing analytical work; and A procedure: For periodically monitoring the purity of chemicals used as reference standards; and That defines which postmortem forensic toxicology tests are to be performed on each type of case.