105 CMR 130.128
Annual Review
Hospitals with emergency departments shall conduct an annual review of security,
wayfinding, signage and lighting policies and procedures, technologies and features. At
minimum, the review shall take place during the daytime and nighttime, and shall include plans
to maintain and keep lighting, footpaths and signs clear of debris, vegetation, or snow; include
a review of surveillance monitoring and patrols by hospital security; include a review of the
effectiveness of hospital signs and symbols for patients for whom English is not their first
language; and any additional requirements included in guidelines of the Department. Hospital
personnel from multiple departments, including security, facilities maintenance, risk
management and the emergencydepartment, or their equivalent positions, shall participate in the
annual review. Policies and procedures should be reviewed annually and made available to DPH
upon request.