.28 Emergency and Disaster Plan.

A. A licensed acute general hospital or special hospital shall comply with the Emergency Management standards outlined in the Hospital Accreditation Standards (2009 Edition), pages 47—68 with the exception of standard EM.02.02.13, pages 61—65.

B. A licensee shall prepare an executive summary of the hospital's evacuation procedures to provide to a patient, family member, or legal representative upon request. The summary shall:

(1) Describe the hospital's Emergency Operation Plan (EOP), which is discussed throughout the Emergency Management standards cited in §A(1) of this regulation; and

(2) Describe the role and responsibilities of a patient, family member, or legal representative in the event of an emergency situation.

C. A licensee shall have a tracking system to assist the hospital, family members, government representatives, and other authorized stakeholders, to locate and identify patients in the event of displacement due to an emergency or disaster.