R9-10-616. Emergency and Safety Standards for a Hospice Inpatient Facility

A. An administrator of a hospice inpatient facility shall ensure that: 1. A disaster plan is developed, documented, maintained in a location accessible to personnel members and other employees, and, if necessary, implemented that includes: a. When, how, and where patients will be relocated, including: i. Instructions for the evacuation or transfer of patients, ii. Assigned responsibilities for each employee and personnel member, and iii. A plan for providing continuing services to meet patient’s needs; b. How each patient’s medical record will be available to individuals providing services to the patient during a disaster; c. A plan to ensure each patient’s medication will be available to administer to the patient during a disaster; and d. A plan for obtaining food and water for individuals present in the hospice inpatient facility or the hospice inpatient facility’s relocation site during a disaster; 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months; 3. Documentation of a disaster plan review required in subsection (A)(2) is created, is maintained for at least 12 months after the date of the disaster plan review, and includes: a. The date and time of the disaster plan review; b. The name of each personnel member, employee, or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement; 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; and 5. An evacuation path is conspicuously posted on each hallway of each floor of the hospice inpatient facility. B. An administrator shall: 1. Obtain a fire inspection conducted according to the time- frame established by the local fire department or the State Fire Marshal, 2. Make any repairs or corrections stated on the fire inspection report, and 3. Maintain documentation of a current fire inspection.