(a) A limited services rural hospital (LSRH) shall develop, adopt, implement, enforce, and maintain a written emergency preparedness plan. The LSRH shall review and update the plan at least every two years. The plan shall:
(1) be based on and include a documented, facility-based and community-based risk assessment, using an all-hazards approach;
(2) include strategies for addressing emergency events identified by the risk assessment;
(3) identify the services the LSRH has the ability to provide in an emergency and include strategies for addressing and serving the patient population;
(4) include the use of a Texas Health and Human Services Commission (HHSC)-approved process to update patient station availability as requested by HHSC during a public health emergency or state-declared disaster;
(5) include continuity of operations, including delegations of authority and succession plans;
(6) include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation; and
(7) incorporate applicable information listed in subsection (e) of this section and the State of Texas Emergency Management Plan. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator.
(b) An LSRH shall send the plan, which may be subject to review and approval by HHSC, to the local disaster management authority.
(c) The LSRH shall develop the plan through a joint effort of the LSRH governing body, administration, medical staff, LSRH personnel, and emergency medical services partners.
(d) An LSRH shall have an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure.
(e) An LSRH shall develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in subsection (a) of this section, risk assessment at subsection (a)(1) of this section, and the communication plan at subsection (f) of this section. The LSRH shall review and update the policies and procedures at least every two years. The policies and procedures shall at least address the following:
(1) reception, treatment, and disposition of casualties that can be used if a disaster situation requires the LSRH to accept multiple patients;
(2) the process, developed in conjunction with appropriate agencies, for allowing essential health care workers and personnel to safely access their delivery care sites;
(3) providing subsistence needs throughout the duration of the response for staff, volunteers, and patients, whether they evacuate or shelter in place, including:
(4) safe evacuation from the LSRH, which includes the following:
(5) a means to shelter in place for patients, staff, and volunteers who remain in the LSRH;
(6) a system of medical documentation that does the following:
(7) the use of volunteers in an emergency and other staffing strategies, including the process and role for integration of state and federally designated health care professionals to address surge needs during an emergency; and
(8) An LSRH's emergency preparedness policies and procedures shall include the LSRH's role in providing care and treatment at an alternate care site identified by federal and local emergency management officials, in the event of a declared disaster or national emergency in accordance with federal rules, regulations, and associated waivers.
(f) An LSRH must develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. The LSRH shall review and update the communication plan at least every two years. The communication plan shall include:
(1) names and contact information for:
(2) contact information for:
(3) primary and alternate means for communicating with:
(4) procedures for notifying each of the following entities, as soon as practicable, regarding the closure or reduction in hours of operation of the LSRH due to an emergency:
(5) a method for sharing information and medical documentation for patients under the LSRH's care, as necessary, with other health care providers to maintain the continuity of care;
(6) a means, in the event of an evacuation, to notify a patient's emergency contact or contacts of an evacuation and the patient's destination and release patient information as permitted under Code of Federal Regulations Title 45 (45 CFR) §164.510(b)(1)(ii) (relating to Uses and Disclosures Requiring an Opportunity for the Individual to Agree or to Object);
(7) a means of providing information about the general condition and location of patients under the LSRH's care as permitted under 45 CFR §164.510(b)(4);
(8) a means of providing information about the LSRH's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee; and
(9) evidence that the LSRH has communicated prospectively with the local utility and phone companies regarding the need for the LSRH to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly.
(g) An LSRH shall post a phone number listing specific to the LSRH equipment and locale to assist staff in contacting mechanical and technical support in the event of an emergency.
(h) An LSRH must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in subsection (a) of this section, risk assessment in subsection (a)(1) of this section, policies and procedures in subsection (E) of this section, and the communication plan in subsection (f) of this section. The LSRH shall review and update the training and testing program at least every two years.
(1) The LSRH shall:
(2) The LSRH shall conduct exercises to test the emergency plan at least annually. The LSRH shall comply with all of the following requirements.
(3) An LSRH participating in an exercise or responding to a real-life event shall develop an after-action report (AAR) within 60 days after the exercise or event. The LSRH shall retain an AAR for at least three years and be available for review by the local emergency management authority and HHSC. The LSRH shall revise the LSRH's emergency plan, as needed, in response to the AAR.
(i) An LSRH must implement emergency and standby power systems based on the emergency plan set forth in subsection (a) of this section.
(1) The generator shall be located in accordance with the location requirements found in the Health Care Facilities Code (National Fire Protection Association (NFPA) 99 and Tentative Interim Amendments (TIA) 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.
(2) The LSRH shall implement emergency power system inspection and testing requirements found in the Health Care Facilities Code, NFPA 110, and the Life Safety Code.
Cont'd...