Current through Bulletin 2024-06, March 15, 2024
(1) The licensee
shall ensure the safety and well-being of patients and provide for a safe
environment in the event of an emergency or disaster including utility
interruption of gas, water, sewer, fuel or electricity, explosion, fire,
earthquake, bomb threat, flood, windstorm, epidemic, and injury.
(2) The administrator or designee shall
develop a plan, coordinated with state and local emergency or disaster offices,
to respond to emergencies or disasters that is:
(a) documented in writing and lists the
coordinating authorities by name and title;
(b) distributed or made available to any
hospital staff to ensure prompt and efficient implementation;
(c) reviewed and updated as necessary in
coordination with local emergency or disaster management authorities;
and
(d) available for review by the
department.
(3) The
administrator shall take charge of operations during any significant emergency.
If not on the premises, the administrator shall make every reasonable effort to
get to the hospital to relieve subordinates and take charge of the
situation.
(4) The licensee shall
hold and document the response to disaster drills, in addition to fire drills,
on a semi-annual basis for staff.
(5) The licensee shall identify and
prominently post:
(a) the name of the person
in charge;
(b) the names and
telephone numbers of emergency medical personnel or agencies;
(c) emergency transport systems;
and
(d) appropriate communication
with the entities listed in this subsection.
(6) The licensee shall ensure the emergency
response procedures addresses the following:
(a) evacuation of occupants to a safe place
within the hospital or to another location;
(b) delivery of essential care and services
to hospital occupants by alternate means regardless of setting;
(c) delivery of essential care and services
when additional persons are housed in the hospital during an
emergency;
(d) delivery of
essential care and services to hospital occupants when staff is reduced by an
emergency; and
(e) maintenance of
safe ambient air temperatures within the hospital in accordance with Subsection
432-101-16(7).
(7)
(a) The
licensee shall maintain an ambient temperature of 58 degrees Fahrenheit(F) or
14 degrees Celsius(C) within the hospital.
(b) A temperature any lower than 58 degrees F
or 14 degrees C may constitute a danger to the health and safety of the
patients in the hospital and the person in charge shall take immediate and
appropriate action when the temperature meets the minimum threshold.
(c) The licensee shall ensure the local fire
department approves emergency heating.
(8) The licensee shall ensure the emergency
plan delineates and includes:
(a) the person
with decision-making authority for fiscal, medical, and personnel
management;
(b) on-hand personnel,
equipment, and supplies and instructions on how to acquire additional help,
supplies, and equipment after an emergency or disaster;
(c) assignment of personnel to specific tasks
during an emergency;
(d) methods of
communicating with local emergency agencies, authorities, and other appropriate
individuals;
(e) the individuals to
be notified in an emergency in order of priority;
(f) method of transporting and evacuating
patients and staff to other locations; and
(g) conversion of hospital facilities for
emergency use.
(9)
(a) The licensee shall schedule and hold at
least one fire drill per shift per quarter and document the date and time the
drill was held, including a brief description of the event and
participants.
(b) The evacuation of
patients during a drill is optional
(c) The licensee shall maintain documentation
of fire drills for review by the department.
(10)
(a)
The licensee shall have an emergency evacuation plan, written in consultation
with qualified fire safety personnel.
(b) The licensee shall post a physical plant
evacuation diagram delineating evacuation routes, location of fire alarm boxes
and fire extinguishers, and emergency telephone numbers of the local fire
department in exit access ways throughout the hospital.
(c) The written plan shall include
fire-containment procedures and how to use the hospital alarm systems and
signals.
