I can start on that just briefly.
A duty that's written down in a policy is not a duty unless there's an enforcement body. It's just a best practice. It's law enforcement 101. If you have a sign on the side of a highway that says you can only go this fast, and everyone knows there's no police ever watching, people do not follow that rule.
There are no police who can watch now on that duty to document because it's not a legal requirement. Even if it was a legal requirement under the act, the commissioner can just watch you go speeding by and can't stop you, because she has no power to stop anyone.