The facility shall: If an acute care hospital, maintain a stroke unit that meets the requirements of this regulation which: Has designated beds for the care of patients not eligible for fibrinolytic therapy or endovascular therapy through qualified clinical staff who meet the requirements in Regulation .10 of this chapter; Develops a standardized process originating in clinical practice guidelines or evidence-based practice to deliver or facilitate the delivery of clinical care; Develops an individualized plan of care that is based on the patient’s assessed needs and reflects coordination of care with other programs, as determined by patient comorbidities; and Maintains written documentation delineating the function of the stroke unit including: Admission criteria; Discharge criteria; Stroke care protocols; Patient census; Rehabilitation in the hospital; Rehabilitation after discharge; and Outcomes data; or If not an acute care hospital, have a written transfer agreement with a hospital which: Meets the requirements of this chapter; Has an inpatient stroke unit that meets the requirements of this regulation; and Can admit the patient after initial treatment and stabilization.