Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 130.000 - Hospital Licensure
Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES
Section 130.127 - Emergency Department Wayfinding, Signage, Lighting and Security Requirements
Universal Citation: 105 CMR 130.000 MA Code of Regs 130.127
Current through Register 1531, September 27, 2024
On and after January 1, 2024, hospitals with emergency departments must adhere to the wayfinding, signage, and security requirements in 105 CMR 130.127 and in guidelines of the Department.
(A) Signage and Wayfinding.
(1) Public entrances
to the emergency department shall be clearly marked from external approaches
and shall be identified by exterior signage and visible from public
thoroughfares. Signs identifying the emergency department shall read
"EMERGENCY" in all caps in red on a white background or white on a red
background and public entrances to emergency departments when applicable, shall
be distinguishable from the emergency department ambulance entrance.
(2) Emergency department patient drop off and
entry areas and hospital perimeter doors, which include, but may not be limited
to, doors that are locked at night, main entrance doors, emergency department
entrance doors, ambulance entrances and any door a patient may typically use to
enter the hospital, shall be well lit and include directions to the emergency
department. Emergency patient vehicle drop off and external and internal entry
areas shall be lit to be distinguishable from other entrances.
(3) Exterior hospital entry points shall be
clearly identified from all major exterior routes including roadways, public
transportation stops, and vehicular parking.
(4) Exterior hospital emergency department
identification and directional signs shall be sufficiently lit to allow drivers
and pedestrians to see signage after dark and during inclement weather.
Hospitals must place directional signs leading to the emergency department in
such a manner as to ensure visual continuity in accordance with guidance from
the Department.
(5) Exterior
wayfinding shall clearly define the access pathways from public thoroughfares
to the hospital main entrance and emergency department entrance.
(B) Security and Communications.
(1) Hospitals
with an emergency department shall maintain lighted communications technology,
such as two-way live audio-visual communication technology, with duress alarm
features across the grounds of the hospital facility, which shall at a minimum
contain communication devices at the hospital main entrances, emergency
department entrance, ambulance entrances, and any exterior door a patient may
typically use, and in strategic locations around hospital grounds to
communicate with on-duty personnel. Such technology shall be accessible to
people with low vision, hearing loss, difficulties with speech and cognitive
processing. The system shall include emergency duress button stations that are
well marked and lit, and not dependent solely on audio communication.
(2) Hospital security desks and emergency
department front desks shall be staffed 24 hours per day, seven days per week,
or the hospital shall have a phone number posted at these locations that can
connect patients with hospital personnel who can provide immediate
assistance.
(3) Hospitals shall
have written policies and procedures for the video/audio monitoring 24 hours
per day, of exterior entrances and emergency department patient drop off and
entry areas with security technology that includes the ability to record and
play back recordings, and the ability to store recording footage for up to 14
days.
(4) Hospitals shall have
written policies and procedures to ensure that patients on hospital grounds
seeking emergency medical care who cannot physically access the emergency
department are quickly located and are immediately given appropriate
care.
(5) Hospitals shall ensure
that all staff and security have appropriate staff training, including on
disability and disability access at the emergency department and how to
communicate with, accommodate, and provide support for such individuals, as
well as staff responsibilities when patients or companions have difficulty
locating and entering an emergency department.
(6) Hospital emergency departments shall have
a unique street address for navigational purposes unless the emergency
department shares the address with the currently used patient access point and
the address for the emergency department shall be listed on the hospital
homepage.
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