10.07.22.24

.24 Emergency Preparedness.

A. The facility shall be constructed consistent with:

(1) All applicable local fire and building codes; and

(2) The Life Safety Code, NFPA 101, including Chapter 24 of NFPA 101.

B. Hand Extinguishers. Fire extinguishers shall be located on each floor and adjacent to, or in, special hazard areas, such as furnace rooms, boiler rooms, kitchens, or laundries. Fire extinguishers shall be of standard and approved types, and installed and maintained to be conveniently available for use at all times. The hospice house shall properly instruct staff in the use of fire extinguishers.

C. Emergency Plan.

(1) The hospice house shall develop an emergency plan that includes procedures that will be followed before, during, and after an emergency. The emergency plan shall address:

(a) The evacuation, transportation, or shelter in-place of patients;

(b) Notification to families, staff, and the Office of Health Care Quality regarding the action that will be taken concerning the safety and well-being of the patients;

(c) Staff coverage, organization, and assignment of responsibilities; and

(d) The continuity of operation, including:

(i) Procuring essential goods, equipment, and services; and

(ii) Relocation to alternate facilities.

(2) The Hospice House shall have a signed agreement with the facility that will house the program’s patients during an emergency evacuation.

(3) Upon request, the hospice house shall provide access to its emergency plan to local organizations for emergency management and for purposes of coordinating local emergency planning.

(4) The hospice house shall prepare a summary of its evacuation procedures to provide to the patient, family member, or legal representative upon request. The summary shall, at a minimum:

(a) List means of transportation to be used in the event of evacuation;

(b) List alternative facilities to be used in the event of evacuation;

(c) Describe means of communication with family members and legal representatives; and

(d) Describe the role of the patient, family member, or legal representative in the event of evacuation.

D. Evacuation Plans. The facility shall conspicuously post individual floor plans with designated evacuation routes on each floor.

E. Emergency Electrical Power Generator.

(1) Generator Required. A hospice house with 6 or more beds shall have an emergency electrical power generator on the premises.

(2) Generator Specifications. The power source shall be a generating set and prime mover located on the program’s premises with automatic transfer. The emergency generator shall:

(a) Be activated immediately when normal electrical service fails to operate;

(b) Come to full speed and load acceptance within 10 seconds; and

(c) Have the capability of 48 hours of operation from fuel stored on-site.

F. Test of Emergency Power System.

(1) The program shall test the emergency power system once each month.

(2) During testing of the emergency power system, the generator shall be exercised for a minimum of 30 minutes under normal emergency facility connected load.

(3) Results of the test shall be recorded in a permanent log book that is maintained for that purpose.

G. The emergency power system shall provide lighting in the following areas of the facility:

(1) Areas of egress and protection as required by COMAR 29.06.01 State Fire Prevention Code and Life Safety Code 101 as adopted by the State Fire Prevention Commission in COMAR 29.06.01;

(2) Nurses’ station;

(3) Medication area;

(4) An area for emergency telephone use;

(5) Boiler or mechanical room;

(6) Kitchen;

(7) Emergency generator location and switch gear location;

(8) If applicable, elevator, if operable on emergency power;

(9) If applicable, areas where life-support equipment is used;

(10) If applicable, common areas or areas of refuge; and

(11) If applicable, toilet rooms of common areas or areas of refuge.

H. Emergency electrical power shall be provided for the following, if applicable:

(1) Nurses’ call system;

(2) At least one telephone in order to make and receive calls;

(3) Fire pump;

(4) Sewerage pump and sump pump;

(5) If applicable, an elevator, if required, for evacuation purposes;

(6) If necessary, heating equipment needed to maintain a minimum temperature of 70ºF (24ºC);

(7) If applicable, life support equipment; and

(8) Nonflammable medical gas systems.

I. Common Areas or Areas of Refuge. If the emergency power system does not provide heat to all patient rooms and toilet rooms, the program shall provide common areas or areas of refuge for all patients. The areas shall meet the following requirements:

(1) The common area or areas of refuge shall maintain a minimum temperature of 70ºF (24ºC); and

(2) Heated toilet rooms shall be provided adjacent to the common areas or areas of refuge.

J. Orientation. The hospice house shall:

(1) Orient staff to the emergency plan and to their individual responsibilities within 24 hours of the commencement of job duties; and

(2) Document completion of the orientation in the staff member’s personnel file through the signature of the employee.

K. Drills.

(1) Fire Drills. The hospice house shall:

(a) Conduct fire drills at least quarterly on all shifts; and

(b) Document completion of each drill.

(2) Documentation. The hospice house shall:

(a) Have the documentation referenced in §K(1)(b) of this regulation signed by all staff who participated in the drill; and

(b) Maintain the documentation on file for a minimum of 2 years.

L. Disaster Drill or Training Session.

(1) The hospice house shall:

(a) Conduct an annual disaster drill or training session, other than a fire drill, on all shifts; and

(b) Document completion of each disaster drill or training session.

(2) Documentation. The hospice house shall:

(a) Have the documentation referenced in §L(1)(b) of this regulation signed by all staff who participated in the drill or training; and

(b) Keep the documentation on file for a minimum of 2 years.