Current through Register No. 40, October 3, 2024
(a) Each facility
shall have an emergency management committee, of which the facility
administrator shall be a member.
(b) The emergency management committee shall
have the authority for developing, implementing, exercising, and evaluating an
emergency management program.
(c)
An emergency management program shall include other individuals who have
knowledge of the facility and the capability to identify resources from key
functional areas within the facility and shall solicit applicable external
representation including but not limited to:
(1) Elected state and local officials;
(2) Police, fire, civil defense,
and public health professionals;
(3) Environment, transportation, and hospital
officials;
(4) Facility
representatives; and
(5)
Representatives from community groups and the media.
(d) An emergency management program shall
include, at a minimum, the following elements:
(1) The emergency management plan, as
described in (d) and (e) below;
(2) The roles and responsibilities of the
committee members;
(3) How the
plan is implemented, exercised, and maintained; and
(4) Accommodation for emergency food and
water supplies.
(e) The
emergency management committee shall develop and institute a written emergency
preparedness plan to respond to a disaster or an emergency.
(f) The plan in (e) above shall:
(1) Include site-specific plans for the
protection of all persons on-site using an all hazards approach, in the event
of fire, natural disaster, or severe weather and human-caused emergency to
include missing patients and bomb threat;
(2) Be approved by the local emergency
management director and reviewed and approved, as appropriate, by the local
fire department;
(3) Be available
to all personnel;
(4) Be based on
realistic conceptual events;
(5)
Be modeled on the incident command system (ICS) in coordination with local
emergency response agencies;
(6)
Provide that all personnel designated or involved in the emergency operations
plan of the facility shall be supplied with a means of identification, such as
vests, baseball caps, or hard hats, which shall be worn at all times in a
visible location during the emergency;
(7) Develop and implement a strategy to
prevent an incident that threatens life, property, and the environment of the
facility;
(8) Develop and implement
a mitigation strategy that includes measures to be taken to limit or control
the consequences, extent, or severity of an incident that cannot be prevented;
(9) Develop and implement a
protection strategy to protect life, property, and the environment from human
caused incidents and events and from natural disasters;
(10) For (7) -(9) above, incorporate the
findings of a hazard vulnerability assessment, the results of an analysis of
impact, program constraints, operational experience, and cost-benefit analysis
to provide strategies that can realistically be implemented without requiring
undue expenses to the licensee;
(11) Conduct a facility-wide inventory and
review, to include the property that the facility is located on, to determine
the status of hazards that might be incorporated into the prevention,
protection, and mitigation strategies and to determine the outcome of prior
strategies at least annually;
(12)
Include the licensee's response to both short-term and long-term interruptions
in the availability of utility service in the disaster or emergency, including
establishing contingency plans for continuity of essential building systems or
evacuation to include the following, as applicable:
a. Electricity;
b. Potable water;
c. Non-potable water;
d. HVAC;
e. Fire protection systems;
f. Fuel required for building operations to
include fuel loss, fuel spill, and fuel exposure that creates a hazardous
incident;
g. Fuel for essential
transportation to include fuel loss, fuel spill, and fuel exposure that creates
a hazardous incident;
h. Medical
gas and vacuum systems, if applicable;
i. Communications systems; and
j. Access to essential services, such as
kitchen and laundry services;
(13) Include a plan for alerting and managing
staff in a disaster, and accessing critical incident stress management (CISM),
if necessary;
(14) Identify a
designated media spokesperson to issue news releases and an area where the
media can be assembled, where they will not interfere with the operations of
the facility;
(15) Reflect measures
needed to restore operational capability with consideration of fiscal aspects
because of restoration costs and possible cash flow losses associated with the
disruption;
(16) Include an
educational, competency-based program for the staff, to provide an overview of
the components of the emergency management program and concepts of the ICS and
the staff's specific duties and responsibilities; and
(17) If the facility is located within 10
miles of a nuclear power plant and is part of the New Hampshire Radiological
Emergency Response Plan (RERP), include the required elements of the
RERP.
(g) The licensee
shall conduct and document with a detailed log, including personnel signatures,
2 drills a year, at least one of which shall rehearse mass casualty response
for the licensee with emergency services, disaster receiving stations, or both,
as follows:
(1) Drills and exercises shall be
monitored by at least one designated evaluator who has knowledge of the
licensee's plan and who is not involved in the exercise;
(2) Exercises shall evaluate program plans,
procedures, training, and capabilities to identify opportunities for
improvement;
(3) The licensee
shall conduct a debriefing session not more than 72 hours after the conclusion
of the drill or exercise. The debriefing shall include all key individuals
including observers, administration, clinical staff, and appropriate support
staff; and
(4) Exercises and actual
events shall be critiqued to identify areas for improvement. The critique shall
identify deficiencies and opportunities for improvement based upon monitoring
activities and observations during the exercise. Opportunities for improvement
identified in critiques shall be incorporated in the licensee's improvement
plan.
(h) For the
purposes of emergency preparedness, each licensee shall have in writing, a plan
for the management of emergency food, water, and other supplies, which shall
include:
(1) Assumptions for calculation of
food and water supplies, for maximum number of staff and patients, water source
of supple, either tap or commercial, and expiration in months, tracking of
supplies, rotation of products, and contracts and memorandums of understanding
with food and water suppliers such as:
a.
Enough refrigerated, perishable foods for a 96-hour period;
b. Enough non-perishable foods for a 96-hour
period; and
c. Portable water for a
96-hour period;
(2)
Designated storage location(s); and
(3) Non-food and water, backup supplies
including but not limited to medical, office, and other supplies necessary to
continue operation of the facility and provide necessary care and oversight of
patients during the emergency.
(i) The licensee shall notify the department
and local fire department when a required sprinkler or fire alarm system is out
of service for more than 4 hours in a 24-hour period. The licensee shall be
evacuated or an approved dedicated fire watch shall be provided for all parties
left unprotected by the shutdown until the sprinkler or alarm system has been
returned to service.
(1) If a facility loses
fire sprinkler coverage for more than 10 hours a fire watch must be instituted
per NFPA; or
(2) If a facility
loses fire alarm coverage for more than 4 hours a fire watch shall be
instituted per Centers for Medicare/Medicaid Services (CMS) or for
non-certified facilities 8 hours per NFPA.
(j) The licensee shall notify the department
when the emergency power has been utilized for 6 or more hours due to power
outage.
(k) If there is an incident
including, but not limited to, fire, toxic fumes including smoke that requires
the evacuation of the hospital all or in part, the hospital shall notify the
department immediately by phone and within 72 hours in writing. A full
follow-up written report on the incident shall be completed and submitted to
the department when the investigation has been conducted and completed,
including what the incident was, action taken, injuries and or deaths that
occurred during incident including during evacuation, emergency procedures
followed, notification of emergency services including local fire departments
and the corrective actions taken.
#9580, eff
10-24-09
