105 Mass. Reg. 130.128
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 emergency department, or their equivalent positions, shall participate in the annual review. Policies and procedures should be reviewed annually and made available to DPH upon request.
105 CMR 130.128