Current through Register Vol. 50, No. 12, December 20, 2024
A. The hospital
shall have an emergency preparedness plan designed to manage the consequences
of natural disasters or other emergencies that disrupt the hospital's ability
to provide care and treatment or threatens the lives or safety of the hospital
patients and/or the community it serves. The emergency preparedness plan shall
be made available, upon request or if mandated to do so, to local, parish,
regional and/or state emergency planning organizations, LDH and the OSFM and
shall include the four core elements of emergency preparedness:
1. comprehensive risk assessment and
emergency planning of:
a. all hazards likely
in geographic area;
b. care-related
emergencies;
c. equipment and power
failures;
d. interruption in
communications, including cyber-attacks;
e. loss of all/portion of facility;
f. loss of all/portion of supplies;
and
g. reviewed and updated at
least every 2 years;
2.
communication plan that:
a. complies with
federal and state laws;
b. has a
system to contact staff, including patients' physicians, other necessary
persons; and
c. is well-coordinated
within the facility, across healthcare providers, and with state and local
public health departments and emergency management
agencies;
3. policies and
procedures that comply with federal and state laws; and
4. training and testing that:
a. complies with federal and state laws;
and
b. are maintained, reviewed, and
updated at least every two years.
B. As a minimum, the plan shall include the
following:
1. an all hazards risk assessment
and identification of potential hazards that could necessitate an evacuation,
including internal and external disasters such as a natural disaster, acts of
bio-terrorism, weapons of mass destruction, labor work stoppage, or industrial
or nuclear accidents;
2. emergency
procedures for evacuation of the hospital;
3. comprehensive measures for receiving and
managing care for a large influx of emergency patients. At a minimum, these
measures shall include the following roles:
a. the emergency department/s
ervices;
4. comprehensive
plans for receiving patients who are being relocated from another facility due
to a disaster. This plan shall include at least an estimate of the number and
type of patients the facility would accommodate and current contact information
for receiving hospitals and other facilities;
5. procedures in the case of interruption of
utility services that address the provision of alternate sources of energy to
maintain:
a. temperatures to protect patient
health and safety and for the safe and sanitary storage of
provisions;
b. emergency lighting;
and
c. fire detection,
extinguishing;
6.
identification of the facility and an alternate facility to which evacuated
patients would be relocated;
7. the
estimated number of patients and staff that would require relocation in the
event of an evacuation;
8. the
system or procedure to ensure that medical charts accompany patients in the
event of a patient evacuation and that supplies, equipment, records, and
medications would be transported as part of an evacuation;
9. the roles and responsibilities of staff
members in implementing the disaster plan; and
10. a system to track on-duty staff and
sheltered patients during the emergency.
C. The hospital shall assure that patients
receive nursing care throughout the period of evacuation and while being
returned to the original hospital.
D. The hospital shall ensure that evacuated
patients, who are not discharged, are returned to the hospital after the
emergency is over, unless the patient prefers to remain at the receiving
facility or be discharged instead of being returned to the original
hospital.
E. Any staff member who
is designated as the acting administrator shall be knowledgeable about, and
authorized to implement the hospital's plans in the event of an
emergency.
F. The hospital
administrator shall appoint an individual who shall be responsible for disaster
planning for the hospital.
G. While
developing the hospital's plan for evacuating patients, the disaster planner
shall communicate with the facility or facilities designated to receive
relocated patients for development of a method for sharing information and
medical documentation of evacuated patients.
H. The hospital shall conduct exercises to
test the emergency plan twice per year. The hospital shall do all of the
following:
1. Participate in a full-scale
exercise that is community-based every two years or when a community-based
exercise is not available, conduct an individual, facility based functional
exercise every two years; or if the hospital experiences an actual natural or
man-made emergency that requires activation of the emergency plan, the hospital
is exempt from engaging in its next required community-based or individual,
facility-based full-scale exercise for one year following the onset of the
actual event.
2. Conduct an
additional exercise at least every two years opposite the year the full-scale
or functional exercise under number one above is conducted, that may include,
but is not limited to the following:
a. a
second full-scale exercise that is community-based or individual,
facility-based functional exercise;
b. a mock disaster drill; or
c. a tabletop exercise or workshop that is
led by a facilitator and includes a group discussion;
3. Analyze the hospital's response to and
maintain documentation of all drills, tabletop exercises, and emergency events,
and revise the hospital's emergency plan as needed.
I. The hospital shall also conduct at least
one drill each year, in which a large influx of emergency patients is
simulated. An actual emergency of this type shall be considered a drill, if it
is documented.
J. In case of an
emergency, the hospital shall have a policy for supply of food and
water.
K. The hospital shall have a
policy for the provision of emergency sources (e.g., generators) of critical
utilities such as electricity, natural gas, water and fuel during any period in
which the normal supply is temporarily disrupted.
L. The hospital's plan shall be developed in
coordination with the local/parish office of emergency preparedness, utilizing
community wide resources.
M. A
hospital may temporarily exceed its licensed capacity in emergency situations,
such as during a declared emergency. Such hospitals shall notify LDH in writing
of the situation within 24 hours or as soon as practical thereafter.
N. Effective immediately, upon declaration of
the secretary and notification to the Louisiana Hospital Association, all
hospitals licensed in Louisiana shall file an electronic report with the Mstat,
or a successor emergency support function (ESF)-8 portal operating system
during a declared emergency, disaster, or public health emergency.
1. The electronic report shall be filed once
a day or in accordance with federal, state, and local statutes, regulations,
and guidance throughout the duration of the disaster or emergency event or as
directed by the department.
2. The
electronic report shall include, but not be limited to the following:
a. status of operation (open, limited or
closed);
b. availability of beds by
category (medical/surgery, intensive care unit, pediatric, psychiatric,
etc.);
c. other resources that may
be needed by a hospital in an emergency (blood products, fuel, pharmaceuticals,
personnel, etc.);
e. evacuation status;
and
f. shelter in place
status.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.36:254 and
R.S.
40:2100-2115.
