Alaska Administrative Code
Title 7 - Health and Social Services
Part 1 - Administration
Chapter 12 - Facilities and Local Units
Article 12 - General Provisions
7 AAC 12.860 - Risk management

(1) provision for monitoring, evaluating, identifying, correcting, and reassessing care practices that negatively affect quality of care and services provided or result in accident or injury to a patient, resident, or staff, and provisions for documenting deficiencies found and remedial actions taken;

(2) a preventive maintenance program that is designed to ensure the proper functioning, safety and performance of all electrical and mechanical equipment used in the care, diagnosis, and treatment of patients or residents, and for the physical plant including the electrical, plumbing, heating, and ventilation systems and their parts, including

(3) a procedure to investigate, analyze, and respond to patient or resident grievances that relate to patient or resident care;

(4) a job-specific orientation program and an in-service training program for each employee that provides annual instruction in

(5) provision of 24-hour emergency service by a physician, on site or on call, including posting the on-call physician's name and phone number at each nursing station; a frontier extended stay clinic or free-standing birth center is exempt from the requirements of this paragraph;

(6) quarterly fire drills for each work shift, a record showing when each drill was held, and coordination with community or area mass casualty drills;

(7) an annual review of written policies and procedures approved, signed, and dated by the administrator or the administrator's designee;

(8) a training program by an instructor certified in cardiopulmonary resuscitation (CPR) for all personnel who are engaged in patient care; the training program must include certification of employees by an approved organization;

(9) a method of ensuring safe storage and transportation of gas cylinder tanks; and

(10) a disaster plan developed in coordination with the local community to address the facility's response in case of a disaster; the plan must include community and state resources for staffing and supplies, and prioritized options to account for staffing shortages, disruptions in the supply line, community allocation of staff resources, telephone triage, and plans for establishing and maintaining communication with local, state, and federal emergency response agencies; the disaster plan must be in place on or before January 1, 2007, and must address response to