Current through Register No. 40, October 3, 2024
(a) Each facility
shall have group, known as an emergency management committee, with the
authority for developing, implementing, exercising, and evaluating the
emergency management program. The committee shall include the facility
administrator and others 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, as appropriate.
(b) The emergency management committee shall
develop and institute a written emergency preparedness plan (plan) to respond
to a disaster or an emergency.
(c)
The plan in (b) above shall:
(1) Include
site-specific plans for the protection of all persons on-site in the event of
fire, natural disaster, severe weather, and human-caused emergency to include,
but not be limited to, missing individuals 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 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 an 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. 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
Critical Incident Stress Management (CISM), if necessary;
(14) Include the management of individuals,
particularly with respect to physical and clinical issues to include:
a. Relocation of individuals with their
medical record including the medicine administration records, if time permits,
as detailed in the emergency plan;
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 won't 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 New Hampshire Radiological
Emergency Response Plan (RERP), include the required elements of the
RERP.
(d) 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 and exercises shall be
monitored by at least one designated evaluator who has knowledge of the
facility's plan and who is not involved in the exercise;
(2) Drills and exercises shall evaluate
program plans, procedures, training, and capabilities to identify opportunities
for improvement;
(3) The facility
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 facility's improvement
plan.
(e) For the
purposes of emergency preparedness, each licensee shall have the following
supplies of foods and water maintained on the premises based on the average
daily census of individuals and staff:
(1)
Enough refrigerated, perishable foods for a 3-day period;
(2) Enough non-perishable foods for a 7-day
period; and
(3) Potable water for a
3-day period.
(f) Each
licensee shall have, in writing, a plan for the management of emergency food
and water supplies required in (e) above. The plan shall include the following:
(1) Assumptions for calculations of food and
water supplies including maximum number of staff and individuals, water source
of supply (tap or commercial) and expiration (months) , tracking of supplies,
and rotation of products, contracts and memorandums of understanding with food
and water suppliers;
(2) Storage
location(s); and
(3) Back-up
supplies.