R9-9A-302. Emergency and Safety Standards

A. An administrator of a non-accredited procurement organization shall ensure that: 1. Standard operating procedures are developed, documented, and maintained for the emergency transfer of non-transplant anatomical donations and non-transplant anatomical material to a designated back-up storage facility when the quality or security of non-transplant anatomical donations or non-transplant anatomical material may be compromised, including: a. The situations that would require an emergency transfer, including time limits and temperature tolerance for loss of refrigeration capability; b. The location of the back-up storage facility; c. The actions to be taken by the administrator and personnel members; d. The methods to be used for the emergency transfer; e. Specific labeling indicating that the transported non- transplant anatomical donations and non-transplant anatomical material must remain untouched until returned to the licensed non-accredited procurement facility after the situation has been resolved; and f. Requirements for the situation that resulted in an emergency transfer to be reviewed through the quality management program in R9-9A-203(A)(3) to prevent a recurrence; 2. A first aid kit is available at the procurement organization; 3. Smoke detectors are: a. Installed according to building size and the requirements of the local zoning jurisdiction; b. Maintained in an operable condition; and c. Either battery operated or, if hard-wired into the electrical system of the procurement organization, have a back-up battery; 4. A portable fire extinguisher that is labeled 2A-10-BC by the Underwriters Laboratory: a. Is readily available for use; b. For a disposable fire extinguisher, is replaced when the fire extinguisher’s indicator reaches the red zone; and c. For a non-disposable fire extinguisher, is serviced at least every 12 months and has a tag attached to the fire extinguisher that includes the date of service; and 5. A written fire and evacuation plan is established and maintained. B. An administrator of a non-accredited procurement organization 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.