Current through Register No. 40, October 3, 2024
(a) Each facility
shall have an individual or 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, or severe weather and human-caused emergency, to
include missing clients and bomb threats;
(2) Be reviewed and approved by the local
emergency management director and 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 on an annual basis;
(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:
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.
Communications systems; and
i.
Essential services, such as kitchen and laundry;
(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 clients, particularly with respect to physical and clinical
issues to include:
a. Relocation of clients
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 plan for
radiological emergency preparedness, include this plan in the event of a
radiological disaster or emergency.
(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 areas of non-compliance 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 food and water maintained on the premises based on the
average daily census of clients and staff:
(1)
Enough refrigerated, perishable food for a 3-day period;
(2) Enough non-perishable food 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, including the following:
(1) Assumptions for calculations of food and
water supplies including maximum number of staff and clients, water source of
supply, whether tap or commercial, and expiration in 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.