Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 3 - BEHAVIORAL HEALTH INPATIENT FACILITIES
Section R9-10-322 - Emergency and Safety Standards
Universal Citation: AZ Admin Code R 9-10-322
Current through Register Vol. 30, No. 38, September 20, 2024
A. An administrator shall ensure that a behavioral health inpatient facility has:
1. A fire alarm system installed according to
the National Fire Protection Association 72: National Fire Alarm and Signaling
Code, incorporated by reference in R9-10-104.01, and a sprinkler system
installed according to the National Fire Protection Association 13 Standard for
the Installation of Sprinkler Systems, incorporated by reference in
R9-10-104.01, that are in working order; or
2. An alternative method to ensure a
patient's safety, documented and approved by the local jurisdiction.
B. An administrator shall ensure that:
1. A disaster plan is developed,
documented, maintained in a location accessible to personnel members and other
employees, and, if necessary, implemented that includes:
a. When, how, and where patients will be
relocated;
b. How a patient's
medical record will be available to individuals providing services to the
patient during a disaster;
c. A
plan to ensure each patient's medication will be available to administer to the
patient during a disaster; and
d. A
plan for obtaining food and water for individuals present in the behavioral
health inpatient facility or the behavioral health inpatient facility's
relocation site during a disaster;
2. The disaster plan required in subsection
(B)(1) is reviewed at least once every 12 months;
3. Documentation of a disaster plan review
required in subsection (B)(2) is created, is maintained for at least 12 months
after the date of the disaster plan review, and includes:
a. The date and time of the disaster plan
review;
b. The name of each
personnel member, employee, volunteer, or student participating in the disaster
plan review;
c. A critique of the
disaster plan review; and
d. If
applicable, recommendations for improvement;
4. A disaster drill for employees is
conducted on each shift at least once every three months and
documented;
5. An evacuation drill
for employees and patients:
a. Is conducted at
least once every six months; and
b.
Includes all individuals on the premises except for:
i. A patient whose medical record contains
documentation that evacuation from the behavioral health inpatient facility
would cause harm to the patient, and
ii. Sufficient personnel members to ensure
the health and safety of patients not evacuated according to subsection
(B)(5)(b)(i);
6. Documentation of each evacuation drill is
created, is maintained for at least 12 months after the date of the evacuation
drill, and includes:
a. The date and time of
the evacuation drill;
b. The amount
of time taken for employees and patients to evacuate to a designated
area;
c. If applicable:
i. An identification of patients needing
assistance for evacuation, and
ii.
An identification of patients who were not evacuated;
d. Any problems encountered in conducting the
evacuation drill; and
e.
Recommendations for improvement, if applicable; and
7. An evacuation path is conspicuously posted
on each hallway of each floor of the behavioral health inpatient
facility.
C. An administrator shall:
1. Obtain a fire
inspection conducted according to the time-frame established by the local fire
department or the State Fire Marshal,
2. Make any repairs or corrections stated on
the fire inspection report, and
3.
Maintain documentation of a current fire inspection.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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