Current through Register Vol. 51, No. 19, September 20, 2024
A. The
facility shall be constructed consistent with:
(1) All applicable local fire and building
codes; and
(2) The Life Safety
Code, NFPA 101, including Chapter 24 of NFPA 101.
B. Hand Extinguishers. Fire extinguishers
shall be located on each floor and adjacent to, or in, special hazard areas,
such as furnace rooms, boiler rooms, kitchens, or laundries. Fire extinguishers
shall be of standard and approved types, and installed and maintained to be
conveniently available for use at all times. The hospice house shall properly
instruct staff in the use of fire extinguishers.
C. Emergency Plan.
(1) The hospice house shall develop an
emergency plan that includes procedures that will be followed before, during,
and after an emergency. The emergency plan shall address:
(a) The evacuation, transportation, or
shelter in-place of patients;
(b)
Notification to families, staff, and the Office of Health Care Quality
regarding the action that will be taken concerning the safety and well-being of
the patients;
(c) Staff coverage,
organization, and assignment of responsibilities; and
(d) The continuity of operation, including:
(i) Procuring essential goods, equipment, and
services; and
(ii) Relocation to
alternate facilities.
(2) The Hospice House shall have a signed
agreement with the facility that will house the program's patients during an
emergency evacuation.
(3) Upon
request, the hospice house shall provide access to its emergency plan to local
organizations for emergency management and for purposes of coordinating local
emergency planning.
(4) The hospice
house shall prepare a summary of its evacuation procedures to provide to the
patient, family member, or legal representative upon request. The summary
shall, at a minimum:
(a) List means of
transportation to be used in the event of evacuation;
(b) List alternative facilities to be used in
the event of evacuation;
(c)
Describe means of communication with family members and legal representatives;
and
(d) Describe the role of the
patient, family member, or legal representative in the event of
evacuation.
D. Evacuation Plans. The facility shall
conspicuously post individual floor plans with designated evacuation routes on
each floor.
E. Emergency Electrical
Power Generator.
(1) Generator Required. A
hospice house with 6 or more beds shall have an emergency electrical power
generator on the premises.
(2)
Generator Specifications. The power source shall be a generating set and prime
mover located on the program's premises with automatic transfer. The emergency
generator shall:
(a) Be activated immediately
when normal electrical service fails to operate;
(b) Come to full speed and load acceptance
within 10 seconds; and
(c) Have the
capability of 48 hours of operation from fuel stored on-site.
F. Test of Emergency
Power System.
(1) The program shall test the
emergency power system once each month.
(2) During testing of the emergency power
system, the generator shall be exercised for a minimum of 30 minutes under
normal emergency facility connected load.
(3) Results of the test shall be recorded in
a permanent log book that is maintained for that purpose.
G. The emergency power system shall provide
lighting in the following areas of the facility:
(1) Areas of egress and protection as
required by COMAR 29.06.01 State Fire Prevention Code and Life Safety Code 101
as adopted by the State Fire Prevention Commission in COMAR 29.06.01;
(2) Nurses' station;
(3) Medication area;
(4) An area for emergency telephone
use;
(5) Boiler or mechanical
room;
(6) Kitchen;
(7) Emergency generator location and switch
gear location;
(8) If applicable,
elevator, if operable on emergency power;
(9) If applicable, areas where life-support
equipment is used;
(10) If
applicable, common areas or areas of refuge; and
(11) If applicable, toilet rooms of common
areas or areas of refuge.
H. Emergency electrical power shall be
provided for the following, if applicable:
(1)
Nurses' call system;
(2) At least
one telephone in order to make and receive calls;
(3) Fire pump;
(4) Sewerage pump and sump pump;
(5) If applicable, an elevator, if required,
for evacuation purposes;
(6) If
necessary, heating equipment needed to maintain a minimum temperature of
70°F (24°C);
(7) If
applicable, life support equipment; and
(8) Nonflammable medical gas
systems.
I. Common Areas
or Areas of Refuge. If the emergency power system does not provide heat to all
patient rooms and toilet rooms, the program shall provide common areas or areas
of refuge for all patients. The areas shall meet the following requirements:
(1) The common area or areas of refuge shall
maintain a minimum temperature of 70°F (24°C); and
(2) Heated toilet rooms shall be provided
adjacent to the common areas or areas of refuge.
J. Orientation. The hospice house shall:
(1) Orient staff to the emergency plan and to
their individual responsibilities within 24 hours of the commencement of job
duties; and
(2) Document completion
of the orientation in the staff member's personnel file through the signature
of the employee.
K.
Drills.
(1) Fire Drills. The hospice house
shall:
(a) Conduct fire drills at least
quarterly on all shifts; and
(b)
Document completion of each drill.
(2) Documentation. The hospice house shall:
(a) Have the documentation referenced in
§K(1)(b) of this regulation signed by all staff who participated in the
drill; and
(b) Maintain the
documentation on file for a minimum of 2 years.
L. Disaster Drill or Training Session.
(1) The hospice house shall:
(a) Conduct an annual disaster drill or
training session, other than a fire drill, on all shifts; and
(b) Document completion of each disaster
drill or training session.
(2) Documentation. The hospice house shall:
(a) Have the documentation referenced in
§L(1)(b) of this regulation signed by all staff who participated in the
drill or training; and
(b) Keep the
documentation on file for a minimum of 2 years.
