La. Admin. Code tit. 48 § I-4581

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4581 - Emergency Preparedness and Emergency Procedures

A. Disaster and emergency plans shall be developed by the governing body, and updated annually, which are based on a risk assessment using an all hazards approach for both internal and external occurrences. Disaster and emergency plans shall include provisions for persons with disabilities.

B. The ASC shall develop and implement policies and procedures based on the emergency plan, risk assessment and communication plan which shall be reviewed and updated at least annually. Such policies shall include a system to track on duty staff and sheltered patients, if any, during the emergency.

C. The ASC shall develop and maintain an emergency preparedness communication plan that complies with both federal and state laws. Patient care shall be well-coordinated within the ASC, across health care providers and with state and local public health departments and emergency systems.

D. The ASC shall develop and maintain training and testing programs, including initial training in policies and procedures and demonstrate knowledge of emergency procedures. Such training shall be provided at least annually.

E. Additional Requirements

1. Each ASC shall post exit signs and diagrams conspicuously through the facility.

2. Flash lights or battery operated lamps for emergency use shall be available for ASC personnel and kept in operational condition.

3. The ASC shall ensure that emergency equipment is:

a. immediately available for use during emergency situations;

b. appropriate for the ASC's patient population; and

c. maintained by appropriate personnel.

4. The ASC shall have written policies and procedures that address the availability and relevant use of the following emergency equipment in the ASC's operating/procedure rooms sufficient in number to handle multiple simultaneous emergencies:

a. emergency call system;

b. oxygen;

c. mechanical ventilatory assistance equipment, including:

i. airways;

ii. manual breathing bag; and

iii. ventilator;

d. cardiac defibrillator;

e. cardiac monitoring equipment;

f. tracheostomy set;

g. laryngoscope and endotracheal tubes;

h. suction equipment; and

i. any other emergency medical equipment and supplies specified by the medical staff and approved by the governing body for treatment of all age groups serviced in the ASC.

5. The ASC shall have an operable backup generator of sufficient size to support and maintain necessary life-sustaining medical equipment.

a. A sufficient amount of fuel shall be maintained to ensure the operation of the generator for at least four hours to maintain:

i. temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

ii. emergency lighting; and

iii. fire detection, extinguishing and alarm systems.

6. The ASC is responsible for:

a. developing and implementing policies and procedures for the safe emergency transfer of patients from the ASC in the event that an emergency impacts the ASCs ability to provide services;

b. developing policies that address what types of emergency procedures, equipment and medications shall be available; and

c. providing trained staff to sustain the life of the patient prior to the transfer.

La. Admin. Code tit. 48, § I-4581

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 431753 (9/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2131-2141.