Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Subchapter T - ADMINISTRATION
Section 554.1914 - Emergency Preparedness and Response
Universal Citation: 26 TX Admin Code ยง 554.1914
Current through Reg. 49, No. 38; September 20, 2024
(a) Definitions. In this section:
(1) "emergency
situation" means an impending or actual situation that:
(A) interferes with normal activities of a
facility and its residents;
(B)
may:
(i) cause injury or death to a resident
or staff member of the facility; or
(ii) cause damage to facility
property;
(C) requires
the facility to respond immediately to mitigate or avoid the injury, death,
damage or interference; and
(D)
does not include a situation that arises from the medical condition of a
resident, such as cardiac arrest, obstructed airway, or cerebrovascular
accident;
(2) "plan"
refers to a facility's emergency preparedness and response plan; and
(3) "receiving facility" means a facility or
location that has agreed to receive the residents of another facility who are
evacuated due to an emergency situation.
(b) Administration. A facility must:
(1) develop and implement a written plan as
described in subsection (c) of this section;
(2) maintain a current printed copy of the
plan in a central location that is accessible to all staff at all times and at
a work station of each personnel supervisor who has responsibilities under the
plan;
(3) evaluate the plan to
determine if information in the plan needs to change:
(A) within 30 days after an emergency
situation;
(B) due to remodeling or
making an addition to the facility; and
(C) at least annually;
(4) revise the plan within 30 days after
information in the plan changes; and
(5) maintain documentation of compliance with
this section.
(c) Emergency Preparedness and Response Plan. A facility's plan must:
(1) include a risk assessment of all
potential internal and external emergency situations relevant to the facility's
operations and geographical area, such as a fire, failure of heating and
cooling systems, a power outage, a bomb threat, an explosion, a hurricane, a
tornado, a flood, extreme snow and ice conditions for the area, a wildfire,
terrorism, a hazardous materials accident, or a thunderstorm with a risk for
harm to persons or property;
(2)
include a description of the facility's resident population;
(3) include a section for each core function
of emergency management, as described in subsection (d) of this section, that
is based on a facility's decision to either shelter-in-place or evacuate during
an emergency situation;
(4) include
a section for a fire safety plan that complies with §
554.326 of this chapter (relating
to Safety Operations); and
(5)
include a section for self reporting incidents that complies with subsection
(f) of this section.
(d) Plan Requirements Regarding Eight Core Functions of Emergency Management.
(1) Direction and control. The facility's
plan must contain a section for direction and control that:
(A) designates by name or title the emergency
preparedness coordinator (EPC), who is the facility staff person with the
authority to manage the facility's response to an emergency situation in
accordance with the plan, and includes the EPC's current phone
number;
(B) designates by name or
title the alternate EPC, who is the facility staff person with the authority to
act as the EPC if the EPC is unable to serve in that capacity, and includes the
alternate EPC's current phone number;
(C) documents the name and contact
information for the local emergency management coordinator (EMC) for the area
where the facility is located, as identified by the office of the local mayor
or county judge;
(D) includes
procedures for notifying the local EMC of the execution of the plan;
(E) includes a plan for coordinating a
staffing response to an emergency situation; and
(F) includes a plan for guiding residents to
a safe location that is based on the type of emergency situation occurring and
a facility's decision to either shelter-in-place or evacuate during an
emergency situation.
(2)
Warning. A facility's plan must contain a section for warning that:
(A) describes how the EPC will be notified of
an emergency situation;
(B)
identifies who the EPC will notify of an emergency situation and when the
notification will occur, including during off hours, weekends, and holidays;
and
(C) addresses monitoring local
news and weather reports regarding a disaster or potential disaster taking into
consideration factors such as geographic specific natural disasters, whether a
disaster is likely to be addressed or forecast in the reports, and the
conditions, natural or otherwise, that would cause staff to monitor news and
weather reports for a disaster.
(3) Communication. A facility's plan must
contain a section for communication that:
(A)
identifies the facility's primary mode of communication to be used during an
emergency situation and the facility's alternate mode of communication to be
used in the event of power failure or the loss of the facility's primary mode
of communication in an emergency situation;
(B) requires posting of the emergency contact
number for the local fire department, ambulance, and police on or near each
telephone in the facility in communities where a "911" emergency management
system is unavailable;
(C) includes
procedures for maintaining a current list of telephone numbers for residents'
responsible parties;
(D) includes
procedures for maintaining a current list of telephone numbers for pre-arranged
receiving facilities;
(E) includes
procedures for maintaining a current list of telephone numbers for the
facility's staff;
(F) identifies
the location of the lists described in subparagraphs (C) through (E) of this
paragraph and in subsection (d)(1)(A) and (B) of this section;
(G) includes procedures to notify:
(i) facility staff about an emergency
situation;
(ii) a receiving
facility about an impending or actual evacuation of residents; and
(iii) residents and residents' responsible
parties about an impending or actual evacuation;
(H) provides a method for a person to obtain
resident information during an emergency situation; and
(I) includes procedures for the facility to
maintain communication with:
(i) facility
staff involved in an emergency situation;
(ii) a receiving facility; and
(iii) the driver of a vehicle transporting
residents, medication, records, food, water, equipment, or supplies during an
evacuation.
(4)
Sheltering Arrangements. A facility's plan must contain a section for
sheltering arrangements that:
(A) includes
procedures for implementing a decision to shelter-in-place that includes:
(i) having access to medications, records,
food, water, equipment and supplies; and
(ii) sheltering facility staff involved in
responding to an emergency situation, and their family members, if
necessary;
(B) includes
procedures for notifying HHSC Regulatory Services regional office for the area
in which the facility is located by telephone immediately after the EPC makes a
decision to shelter-in-place:
(i) before,
during, or after a hurricane or flood impacts a facility, if the risk
assessment identified a hurricane or flood as a potential emergency situation;
or
(ii) after any other type of
emergency situation that has caused property damage to a facility;
(C) includes procedures for
accommodating evacuated residents, if the facility serves as a receiving
facility for a facility that has evacuated.
(5) Evacuation. A facility's plan must
contain a section for evacuation that:
(A)
identifies evacuation destinations and routes, and includes a map that shows
the destinations and routes;
(B)
includes procedures for implementing a decision to evacuate residents to a
receiving facility;
(C) includes a
current copy of an agreement with a receiving facility, outlining arrangements
for receiving residents in the event of an evacuation, if the evacuation
destination identified in accordance with subparagraph (B) of this paragraph is
a receiving facility that is not owned by the same entity as the evacuating
facility;
(D) includes procedures
for:
(i) ensuring facility staff accompany
evacuating residents;
(ii) ensuring
that residents and facility staff present in the building have been
evacuated;
(iii) accounting for
residents and facility staff after they have been evacuated;
(iv) accounting for residents absent from the
facility at the time of the evacuation;
(v) releasing resident information in an
emergency situation to promote continuity of a resident's care;
(vi) contacting the local EMC to find out if
it is safe to return to the geographical area after an evacuation;
(vii) determining if it is safe to re-enter
and occupy the building after an evacuation; and
(E) includes procedures for notifying the
local EMC regarding an evacuation of the facility;
(F) includes procedures for notifying HHSC
Regulatory Services regional office for the area in which the facility is
located by telephone immediately after the EPC makes a decision to evacuate;
and
(G) includes procedures for
notifying HHSC Regulatory Services regional office for the area in which the
facility is located by telephone immediately when residents have returned to
the facility after an evacuation.
(6) Transportation. A facility's plan must
contain a section for transportation that:
(A)
arranges for a sufficient number of vehicles to safely evacuate all
residents;
(B) identifies facility
staff designated to drive a facility owned, leased or rented vehicle during an
evacuation;
(C) includes procedures
for safely transporting residents, facility staff involved in an evacuation;
and
(D) includes procedures for
safely transporting and having timely access to oxygen, medications, records,
food, water, equipment, and supplies needed during an evacuation.
(7) Health and Medical Needs. A
facility's plan must contain a section for health and medical needs that:
(A) identifies the types of services used by
residents, such as dialysis, oxygen, respirator care, or hospice services;
and
(B) ensures the resident's
needs identified in subparagraph (A) of this paragraph are met during an
emergency situation.
(8)
Resource Management. A facility's plan must contain a section for resource
management that:
(A) includes a plan for
identifying medications, records, food, water, equipment and supplies needed
during an emergency situation;
(B)
identifies facility staff who are assigned to locate the items in subparagraph
(A) of this paragraph and who must ensure the transportation of the items
during an emergency situation; and
(C) includes procedures to ensure medications
are secure and maintained at the proper temperature during an emergency
situation.
(e) Training. The facility must:
(1) train a
facility staff member on the staff member's responsibilities under the plan
within 30 days after assuming job duties;
(2) train a facility staff member on the
staff member's responsibilities under the plan at least annually and when the
staff member's responsibilities under the plan change; and
(3) conduct one unannounced annual drill with
facility staff for severe weather and other emergency situations identified by
the facility as likely to occur, based on the results of the risk assessment
required by subsection (c)(1) of this section.
(f) Self-Reported Incidents.
(1) A facility must report a fire to HHSC as
follows:
(A) by calling 1-800-458-9858
immediately after the fire; and
(B)
by submitting a completed HHSC form titled "Fire Report for Long Term Care
Facilities" within 15 calendar days after the fire.
(2) A facility must report an emergency
situation that caused the death or serious injury of a resident to HHSC as
follows:
(A) by calling 1-800-458-9858
immediately after the death or serious injury; and
(B) by submitting a completed HHSC form
titled "HHSC Provider Investigation Report" within 5 working days after making
the telephone report required by paragraph (2)(A) of this subsection.
(g) Emergency Response System.
(1) The facility administrator and
director of nursing must enroll in an emergency communication system in
accordance with instructions from HHSC.
(2) The facility must respond to requests for
information received through the emergency communication system in the format
established by HHSC.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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