Section He-P 802.29 - Emergency Preparedness(a) Each facility shall have an emergency management committee, of which the facility administrator shall be a member.(b) The emergency management committee shall have the authority for developing, implementing, exercising, and evaluating an emergency management program.(c) An emergency management program shall include other individuals who have knowledge of the facility and the capability to identify resources from key functional areas within the facility and shall solicit applicable external representation including but not limited to: (1) Elected state and local officials; (2) Police, fire, civil defense, and public health professionals; (3) Environment, transportation, and hospital officials; (4) Facility representatives; and(5) Representatives from community groups and the media. (d) An emergency management program shall include, at a minimum, the following elements: (1) The emergency management plan, as described in (d) and (e) below; (2) The roles and responsibilities of the committee members; (3) How the plan is implemented, exercised, and maintained; and (4) Accommodation for emergency food and water supplies.(e) The emergency management committee shall develop and institute a written emergency preparedness plan to respond to a disaster or an emergency.(f) The plan in (e) above shall: (1) Include site-specific plans for the protection of all persons on-site using an all hazards approach, in the event of fire, natural disaster, or severe weather and human-caused emergency to include missing patients and bomb threat; (2) Be approved by the local emergency management director and reviewed and approved, as appropriate, by the local fire department; (3) Be available to all personnel; (4) Be based on realistic conceptual events; (5) Be modeled on the incident command system (ICS) in coordination with local emergency response agencies; (6) Provide that all personnel designated or involved in the emergency operations plan of the facility shall be supplied with a means of identification, such as vests, baseball caps, or hard hats, which shall be worn at all times in a visible location during the emergency; (7) Develop and implement a strategy to prevent an incident that threatens life, property, and the environment of the facility;(8) Develop and implement a mitigation strategy that includes measures to be taken to limit or control the consequences, extent, or severity of an incident that cannot be prevented; (9) Develop and implement a protection strategy to protect life, property, and the environment from human caused incidents and events and from natural disasters; (10) For (7) -(9) above, incorporate the findings of a hazard vulnerability assessment, the results of an analysis of impact, program constraints, operational experience, and cost-benefit analysis to provide strategies that can realistically be implemented without requiring undue expenses to the licensee; (11) Conduct a facility-wide inventory and review, to include the property that the facility is located on, to determine the status of hazards that might be incorporated into the prevention, protection, and mitigation strategies and to determine the outcome of prior strategies at least annually; (12) Include the licensee's response to both short-term and long-term interruptions in the availability of utility service in the disaster or emergency, including establishing contingency plans for continuity of essential building systems or evacuation to include the following, as applicable: e. Fire protection systems;f. Fuel required for building operations to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;g. Fuel for essential transportation to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;h. Medical gas and vacuum systems, if applicable;i. Communications systems; andj. Access to essential services, such as kitchen and laundry services;(13) Include a plan for alerting and managing staff in a disaster, and accessing critical incident stress management (CISM), if necessary; (14) Identify a designated media spokesperson to issue news releases and an area where the media can be assembled, where they will not interfere with the operations of the facility;(15) Reflect measures needed to restore operational capability with consideration of fiscal aspects because of restoration costs and possible cash flow losses associated with the disruption; (16) Include an educational, competency-based program for the staff, to provide an overview of the components of the emergency management program and concepts of the ICS and the staff's specific duties and responsibilities; and(17) If the facility is located within 10 miles of a nuclear power plant and is part of the New Hampshire Radiological Emergency Response Plan (RERP), include the required elements of the RERP.(g) The licensee shall conduct and document with a detailed log, including personnel signatures, 2 drills a year, at least one of which shall rehearse mass casualty response for the licensee with emergency services, disaster receiving stations, or both, as follows: (1) Drills and exercises shall be monitored by at least one designated evaluator who has knowledge of the licensee's plan and who is not involved in the exercise; (2) Exercises shall evaluate program plans, procedures, training, and capabilities to identify opportunities for improvement; (3) The licensee shall conduct a debriefing session not more than 72 hours after the conclusion of the drill or exercise. The debriefing shall include all key individuals including observers, administration, clinical staff, and appropriate support staff; and(4) Exercises and actual events shall be critiqued to identify areas for improvement. The critique shall identify deficiencies and opportunities for improvement based upon monitoring activities and observations during the exercise. Opportunities for improvement identified in critiques shall be incorporated in the licensee's improvement plan.(h) For the purposes of emergency preparedness, each licensee shall have in writing, a plan for the management of emergency food, water, and other supplies, which shall include: (1) Assumptions for calculation of food and water supplies, for maximum number of staff and patients, water source of supple, either tap or commercial, and expiration in months, tracking of supplies, rotation of products, and contracts and memorandums of understanding with food and water suppliers such as: a. Enough refrigerated, perishable foods for a 96-hour period;b. Enough non-perishable foods for a 96-hour period; andc. Portable water for a 96-hour period; (2) Designated storage location(s); and(3) Non-food and water, backup supplies including but not limited to medical, office, and other supplies necessary to continue operation of the facility and provide necessary care and oversight of patients during the emergency. (i) The licensee shall notify the department and local fire department when a required sprinkler or fire alarm system is out of service for more than 4 hours in a 24-hour period. The licensee shall be evacuated or an approved dedicated fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler or alarm system has been returned to service.(1) If a facility loses fire sprinkler coverage for more than 10 hours a fire watch must be instituted per NFPA; or(2) If a facility loses fire alarm coverage for more than 4 hours a fire watch shall be instituted per Centers for Medicare/Medicaid Services (CMS) or for non-certified facilities 8 hours per NFPA.(j) The licensee shall notify the department when the emergency power has been utilized for 6 or more hours due to power outage.(k) If there is an incident including, but not limited to, fire, toxic fumes including smoke that requires the evacuation of the hospital all or in part, the hospital shall notify the department immediately by phone and within 72 hours in writing. A full follow-up written report on the incident shall be completed and submitted to the department when the investigation has been conducted and completed, including what the incident was, action taken, injuries and or deaths that occurred during incident including during evacuation, emergency procedures followed, notification of emergency services including local fire departments and the corrective actions taken.N.H. Admin. Code § He-P 802.29
Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.