(a) Safety committee. Each facility shall have a multi-disciplinary safety committee. The facility chief executive officer (CEO) shall appoint the chairman and members of the safety committee.
  (1) Safety officer. The CEO shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall be a member of the safety committee, and shall carry out the functions of the safety program.
  (2) Safety committee meetings. The safety committee shall meet as required by the chairman, but not less than quarterly. Written minutes of each meeting shall be retained for a period of not less than one year.
  (3) Safety activities.
    (A) Incident reports. The safety committee shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded in safety committee minutes are evaluated, and documentation is provided to show follow-up and corrective actions.
    (B) Safety policies and procedures. The facility shall develop, implement and enforce safety policies and procedures for each department or service which are integrated within the overall plan. Unit specific policies and procedures shall be maintained within each department or service.
    (C) Safety training and continuing education. Safety training shall be established as part of new employee orientation and in the continuing education of all employees.
  (4) Written authority. The authority of the safety committee to take action when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.
(b) Emergency preparedness.
  (1) Disaster management. Each facility shall develop plans for effective preparedness, mitigation, response, and recovery from disasters.
  (2) Disaster preparedness. Each facility shall develop a written policy and procedures for the following:
    (A) notification of personnel and patients;
    (B) the receipt, treatment and disposition of casualties;
    (C) the identification of appropriate community resources; and
    (D) evacuation procedures.
  (3) Disaster plans. National Fire Protection Association 99, Standard for Health Care Facilities, 1999 edition, Chapter 11, and the State of Texas Emergency Management Planshall be used as references to plan and establish the disaster plans. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator.
  (4) Annual rehearsal. The facility shall practice the disaster plans at least one time per year and shall document the rehearsal of the plans. Documentation of rehearsals for the last three years shall be retained.
(c) Emergency communication system. An emergency communication system shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments.

Source Note: The provisions of this §510.102 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469