Current through Register No. 40, October 3, 2024
(a) Each facility
shall have an emergency management committee, of which the facility
administrator must be a member.
(b) The emergency management committee shall
have the authority for developing, implementing, exercising, and evaluating an
emergency management program.
(c)
The emergency management committee 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 (e) and (f) below;
(2)
The roles and responsibilities of the committee members;
(3) A description of 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 (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 in the event of fire, natural disaster,
severe weather or human-caused emergency such as missing residents and bomb
threats;
(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 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 including 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 facility;
(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 may be incorporated into the prevention,protection,
and mitigation strategies, and to determine the outcome of prior strategies at
least annually;
(12) Include the
facility'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. Heating, ventilation, and air conditioning
(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. Essential services,
such as kitchen and laundry services;
(13) Include a plan for alerting and managing
staff in a disaster, and accessing CISM, if necessary;
(14) Include the management of residents,
particularly with respect to physical and clinical issues, to include:
a. Relocation of residents, with their
medical record, including the medicine administration records, if time
permits;
b. Access, as appropriate,
to critical materials such as pharmaceuticals, medical supplies, food supplies,
linen supplies, and industrial and potable water; and
c. How to provide security during the
disaster;
(15) 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;
(16) 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;
(17) 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
(18) If the facility is located within 10
miles of a nuclear power plant and is part of the NewHampshire Radiological
Emergency Response Plan (RERP), include the required elements of the
RERP.
(g) The facility
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 facility with emergency services, disaster receiving stations, or both,
as follows:
(1) Drills shall be monitored by
at least one designated evaluator who has knowledge of the facility's plan and
who is not otherwise involved in the drill;
(2) Drills shall evaluate program plans,
procedures, training, and capabilities toidentify opportunities for
improvement;
(3) The facility shall
conduct a debriefing session not more than 72 hours after the conclusion of the
drill. 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 facility'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 calculations of
food and water supplies, for maximum number of staff and residents, water
source of supply, 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 3-day period;
(b) Enough
non-perishable foods for a 7-day period; and
(c) Potable water for a 3-day
period.
(2) Designated
storage location(s); and
(3)
Non-food and water, back-up 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 residents during the
emergency.