6 Colo. Code Regs. § 1009-5 Regulation 2

Current through Register Vol. 47, No. 11, June 10, 2024

Regulation Regulation 2 - Preparations by General or Critical Access Hospitals for Enhanced Situational Awareness, Emergency Preparedness, and Emergency Response

1. Each general or critical access hospital in this state is required to maintain an up-to-date notification list for an emergency epidemic. The list shall include any satellite clinics, acute care facilities, or trauma centers operated by the general or critical access hospital; offices of physicians and health care providers on the staff of the hospital, as available; and the local public health agency and local emergency management office serving the county in which the hospital is located. Each general or critical access hospital is required at least once per year:

(A) to confirm the notification list is accurate and up to date, and

(B) to conduct a notification test or real incident communications by a broadcast fax or another communications method for rapid notification.

2. Each general or critical access hospital in this state shall maintain a plan that the general or critical access hospital will implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic. The plan shall be reviewed and updated as needed but at least every 3 years, and submitted at least every 3 years to CDPHE. In addition, the general or critical access hospital shall review with and make available a copy of the plan(s) submitted pursuant to these regulations to its jurisdiction's local offices of emergency management, local public health or designated health and medical support lead agency, their regional emergency medical and trauma services advisory councils, and healthcare coalition. The plan shall address the following areas:

A) Organization and assignment of employees and medical staff of the general or critical access hospital to work on controlling the emergency epidemic using the National Incident Management System;

B) Having sufficient supplies, training for staff using personal protective equipment, and a process for the provision of personal protective equipment to all staff and employees who are assigned to work in areas where they may be exposed to ill and contagious persons or to infectious agents and waste. Personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions against bacterial and viral infections;

C) Procurement, storage and distribution of at least a three-day supply of an antibiotic as determined by CDPHE, that is effective against category A bacterial agents to be used as prophylaxis for all employees and medical staff immediately responding. The plan shall include procurement of another antibiotic for a small number of employees who may be unable to take the antibiotic of first choice;

D) A process for recruiting and credentialing volunteers who may be asked to work or volunteer as needed to respond to an emergency epidemic;

E) Creation of an operations center within the general or critical access hospital for the purposes of:

(i) centralizing telephone, radio, and other electronic communications;

(ii) compiling morbidity and mortality data including the number of patients, number of available beds, and number of working staff and employees;

(iii) receiving and responding to executive orders of the governor regarding the emergency epidemic;

(iv) maintaining a log of operations, decisions, and resources necessary to maintain operations during the epidemic;

(v) assessment and management of infection control within the general or critical access hospital, and;

(vi) in coordination with local public health agencies and the county coroner, the disposal of human corpses;

F) Security of the facility and traffic management necessary to control unanticipated crowds or traffic;

G) Rapid transport of human diagnostic specimens to the state laboratory or as otherwise directed by CDPHE;

H) Implementation of infection control measures to prevent the spread of the disease to staff, employees, and other patients within the general or critical access hospital;

I) Coordination and communication with other general and critical access hospitals and pre- hospital care agencies to assure that patients with extreme, life-threatening, or emergency medical or traumatic conditions are not diverted from the general and critical access hospital;

J) Triaging all persons during an emergency epidemic in a manner that protects the facility, staff, and public, and routing these persons to the appropriate facility based on their medical status;

K) Organization, staffing, security, and logistics of the receipt, distribution and delivery of antibiotics, antiviral medications, vaccines, or other medical countermeasures delivered from the Strategic National Stockpile (SNS) needed in an emergency epidemic for employees and medical staff, and;

L) Implementation of a back-up communications system, such as 800 megahertz radios or amateur radio emergency services, that will be used for communication if and when telephone communications are disabled or not functioning.

3. Each general and critical access hospital shall conduct at least one exercise of its plan every three years. If the hospital activates its plan in response to one or more actual emergencies, these emergencies can serve in place of emergency response exercises. Each general and critical access hospital shall complete an after-action report and improvement matrix within 60 days of exercise or real incident completion. The report and the improvement matrix will be submitted to CDPHE.

4. Mandatory Hospital Reporting

A) "Staffed-Bed Capacity" means the total number of all staffed acute care inpatient beds.

i) For purposes of this definition, "Staffed" means a bed, in an inpatient unit, that a facility can staff with the appropriate personnel, in accordance with the facility's unit-specific nurse staffing plan.

ii) Acute care beds included in this count may include:

(a) Intensive Care Unit (ICU);

(b) Progressive Care Unit (PCU/Stepdown;

(c) Med/Surg./Tele;

(d) Surge/Overflow;

B) Certified Critical Access Hospitals (CAHS) shall not include swing beds in its Staffed-bed Capacity.

C) The mandatory hospital reporting requirements detailed in this rule do not apply to licensed rehabilitation hospitals, psychiatric hospitals, hospital units, long-term care hospitals, as defined at 42 U.S.C. 1395X(CCC), and specialty hospitals.

D) Calculating Staffed bed Capacity - beginning September 1, 2022, a hospital's baseline Staffed-bed Capacity shall be calculated using the average number of staffed beds reported to the Department by the hospital between January 1, 2022, and June 30, 2022.

(i) The hospital's baseline Staffed-bed Capacity shall be communicated to the hospital in a form and manner determined by the Department.

(ii) A hospital shall have thirty (30) days from notification of its baseline Staffed-bed Capacity to contact the Department and request a recalculation of its baseline Staffed-bed Capacity.

(a) The hospital shall submit supporting data and other information in a form and manner determined by the Department.

(iii) Once initially established, the hospital's baseline Staffed-bed Capacity may be recalculated annually.

(a) The hospital shall articulate in its emergency management plan, as set forth in 6 CCR 1011-1, Chapter 4, a process for recalculating the hospital's original baseline Staffed-bed Capacity. Such recalculation may be an annual recalculation, be based on the hospital's adjustment for a minimum of 2 and a maximum of 4 seasonal variances, and/or based on other anticipated factors affecting Staffed-bed Capacity.

E) Required Reporting - Staffed-Bed Capacity

(i) Each hospital shall report its current staffed-bed capacity, in the form and manner determined by the Department.

(ii) If a hospital's ability to meet Staffed-bed Capacity falls below eighty (80) percent of the hospital's reported baseline for no less than seven (7) and no more than fourteen (14) consecutive days, the hospital shall notify the Department and submit the following:

(a) A plan to ensure staff is available, within thirty (30) days, to return to a staffed-bed capacity level that is eighty (80) percent of the reported baseline; or

(b) A request for a waiver due to a hardship, which request articulates why the hospital is unable to meet the required Staffed-bed Capacity if:

(1) The hospital's current staffed-bed capacity falls below eighty (80) percent of the hospital's reported baseline for no less than seven (7) and no more than fourteen (14) consecutive days, or

(2) The hospitals' current staffed-bed capacity threatens public health.

F. Required Reporting - Additional Data - In addition to the reporting Staffed bed Capacity, all licensed health facilities are required to report any data deemed necessary for situational awareness and emergency preparedness and response, including:

i. The daily maximum number of adult and pediatric beds that are currently or can be made available within 24 hours for patients in need of Intensive Care Unit level care. Reporting shall be made in the form and manner determined by the Department.

ii. The daily maximum number of all staffed acute care beds, including Intensive Care Unit beds, available for patients in need of non-Intensive Care Unit hospitalization. Reporting shall be made in the form and manner determined by the Department.

iii. The daily maximum number of all adult and pediatric Med/Surgical beds, available for patients in need of non-Intensive Care Unit hospitalization. Reporting shall be made in the form and manner determined by the Department.

iv. The Department may require additional crisis-specific reporting as necessary for situational awareness or for emergency preparedness, and response purposes on an ongoing basis.

G. Surge Capacity Reporting

(i) Each hospital with more than twenty-five (25) beds shall articulate in its emergency management plan a demonstrated ability to expand the hospital's Staffed-bed Capacity in compliance with regulations set forth in 6 CCR 1011-1, Chapter 4.

H. Any hospital that fails to comply with these requirements shall be subject to enforcement by the Department pursuant to 6 CCR 1011-1, Chapter 2 and Chapter 4, and Section 25-3-128(5)(D), C.R.S.

6 CCR 1009-5 Regulation 2

38 CR 15, August 10, 2015, effective 9/14/2015

42 CR 08, April 10, 2019, effective 5/15/2019

46 CR 06, March 25, 2023, effective 2/15/2023

46 CR 10, May 25, 2023, effective 6/14/2023