(a) Safety Management. A hospice inpatient unit must maintain a safe physical environment free of hazards for clients, staff, and visitors.
  (1) A hospice inpatient unit must address real or potential threats to the health and safety of the clients, others, and property.
  (2) In addition to §558.256 of this chapter (relating to Emergency Preparedness Planning and Implementation), a hospice inpatient unit must have a written disaster preparedness plan that addresses the core functions of emergency management as described in subparagraphs (A) - (G) of this paragraph. The facility must maintain documentation of compliance with this paragraph.
    (A) The portion of the plan on direction and control must:
      (i) designate a person by position, and at least one alternate, to be in charge during implementation of an emergency response plan, with authority to execute a plan to evacuate or shelter in place;
      (ii) include procedures the facility will use to maintain continuous leadership and authority in key positions;
      (iii) include procedures the facility will use to activate a timely response plan based on the types of disasters identified in the risk assessment;
      (iv) include procedures the facility will use to meet staffing requirements;
      (v) include procedures the facility will use to warn or notify facility staff about internal and external disasters, including during off hours, weekends, and holidays;
      (vi) include procedures the facility will use to maintain a current list of who the hospice will notify once warning of a disaster is received;
      (vii) include procedures the facility will use to alert critical facility personnel once a disaster is identified; and
      (viii) include procedures the facility will use to maintain a current 24-hour contact list for all personnel.
    (B) The portion of the plan on communication must include procedures:
      (i) for continued communication, including procedures during an evacuation to maintain contact with critical personnel and with all vehicles traveling in an evacuation caravan;
      (ii) to maintain an accessible, current list of the phone numbers of:
        (I) client family members;
        (II) local shelters;
        (III) prearranged receiving facilities;
        (IV) the local emergency management agencies;
        (V) other health care providers; and
        (VI) State and federal emergency management agencies;
      (iii) to notify staff, clients, families of clients, families of critical staff, prearranged receiving facilities, and others of an evacuation or the plan to shelter in place;
      (iv) to provide a contact number for out-of-town family members to call for information; and
      (v) to relocate and track clients during disasters that require mass evacuations.
    (C) The portion of the plan on resource management must include procedures:
      (i) to maintain contracts and agreements with vendors as needed to ensure the availability of the supplies and transportation needed to execute the plan to shelter in place or evacuate;
      (ii) to develop accurate, detailed, and current checklists of essential supplies, staff, equipment, and medications;
      (iii) to designate responsibility for completing the checklists during disaster operations;
      (iv) for the safe and secure transportation of adequate amounts of food, water, medications, and critical supplies and equipment during an evacuation; and
      (v) to maintain a supply of sufficient resources for at least seven days to shelter in place, which must include:
        (I) emergency power, including backup generators and accounts for maintaining a supply of fuel;
        (II) potable water in an amount based on population and location;
        (III) the types and amounts of food for the number and types of clients served;
        (IV) extra pharmacy stocks of common medications; and
        (V) extra medical supplies and equipment, such as oxygen, linens, and any other vital equipment.
    (D) The portion of the plan on sheltering in place must:
      (i) be developed using information about the building's construction and Life Safety Code (LSC) systems;
      (ii) describe the criteria to be used to decide whether to shelter in place versus evacuate;
      (iii) include procedures to assess whether the building is strong enough to withstand the various types of possible disasters and to identify the safest areas of the building;
      (iv) include procedures to secure the building against damage;
      (v) include procedures for collaborating with the local emergency management agencies regarding the decision to shelter in place;
      (vi) include procedures to assign each task in the sheltering plan to facility staff;
      (vii) describe procedures to shelter in place that allow the facility to maintain 24-hour operations for a minimum of seven days to maintain continuity of care for the number and types of clients served; and
      (viii) include procedures to provide for building security.
    (E) The portion of the plan on evacuation must:
      (i) include contracts with prearranged receiving facilities, including a hospice inpatient facility, skilled nursing facility, nursing facility, assisted living facility, or hospital, with at least one facility located at least 50 miles away;
      (ii) include procedures to identify and follow evacuation and alternative routes for transporting clients to a receiving facility and to notify the proper authorities of the decision to evacuate;
      (iii) include procedures to protect and transport client records and to match them to each client;
      (iv) include procedures to maintain a checklist of items to be transported with clients, including medications and assistive devices, and how the items will be matched to each client;
      (v) include staffing procedures the facility will use to ensure that staff accompanies evacuating clients when the hospice transports clients to a receiving facility;
      (vi) include procedures to identify and assign staff responsibilities, including how clients will be cared for during evacuations and a backup plan for lack of sufficient staff;
      (vii) include procedures facility staff will use to account for all persons in the building during the evacuation and to track all persons evacuated;
      (viii) include procedures for the use, protection, and security of the identifying information the facility will use to identify evacuated clients;
      (ix) include procedures facility staff will follow if a client becomes ill or dies in route when the hospice transports clients to a receiving facility;
      (x) include procedures to make a hospice counselor available when staff accompanies clients during transport by the hospice to a receiving facility;
      (xi) include the facility's policy on whether family of staff and clients can shelter at the hospice and evacuate with staff and clients;
      (xii) include procedures to coordinate building security with the local emergency management agencies;
      (xiii) include procedures facility staff will use to determine when it is safe to return to the geographical area;
      (xiv) include procedures facility staff will use to determine if the building is safe for reoccupation; and
      (xv) be approved by the local emergency management coordinator (EMC) at least annually and when updated.
    (F) The portion of the plan on transportation must:
      (i) describe how the hospice prearranges for a sufficient number of vehicles to provide suitable, safe transportation for the type and number of clients being served; and
      (ii) include procedures to contact the local EMC to coordinate the facility's transportation needs in the event its prearrangements for transportation fail for reasons beyond the facility's control.
    (G) The portion of the plan on training must include:
      (i) procedures that specify when and how the disaster response plan is reviewed with clients and family members;
      (ii) procedures to review the role and responsibility of a client able to participate with the plan;
      (iii) procedures for initial and periodic training for all facility staff to carry out the plan;
      (iv) the frequency for conducting disaster drills and demonstrations to ensure staff are fully trained with respect to their duties under the plan; and
Cont'd...