6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 7

Current through Register Vol. 47, No. 17, September 10, 2024

Part 7 - EMERGENCY PREPAREDNESS

7.1 Emergency Management Plan

(A) Each hospital shall develop and implement a comprehensive emergency management plan that meets the requirements of this part, utilizing an all-hazards approach. The plan shall take into consideration preparedness for natural emergencies, man-made emergencies, facility emergencies, bioterrorism event, pandemic influenza, or an outbreak by a novel and highly infectious agent or biological toxin, that may include, but are not limited to:

(1) care-related emergencies;

(2) equipment and power failures;

(3) interruptions in communications, including cyber-attacks;

(4) loss of a portion or all of a facility; and

(5) interruptions in the normal supply of essentials, such as water and food.

(B) The emergency management plan shall address, at a minimum, the following:

(1) The plan shall be:

(a) specific to the hospital;

(b) relevant to the geographic area;

(c) readily put into action, twenty-four (24) hours a day, seven (7) days a week; and

(d) updated at least annually and as often as necessary, as circumstances warrant.

(2) The plan shall identify:

(a) who is responsible for each aspect of the plan; and

(b) essential and key personnel responding to a disaster.

(3) The plan shall include:

(a) a staff education and training component;

(b) a process for testing each aspect of the plan at least every two (2) years or as determined by changes in the availability of hospital resources;

(c) a component for debriefing and evaluation after each disaster, incident, or drill;

(d) the actions the hospital will take to maximize staffed-bed capacity and appropriate utilization of hospital beds to the extent necessary for a public health emergency and through the following activities:

(i) cross-training, just-in-time training, and redeployment of staff;

(ii) supporting all hospital facilities, including hospital-owned facilities, to provide any necessary, available, and appropriate preventive care, vaccine administration, diagnostic testing, and therapeutics;

(iii) maximizing hospital throughput by discharging patients to skilled nursing, post-acute, and other step-down facilities; and

(iv) reducing the number of scheduled procedures in the hospital;

(e) A process for recalculating the hospital's original baseline staffed-bed capacity for reporting staffed-bed capacity pursuant to 6 CCR 1009-5, Regulation 2, based on the hospital's adjustment for seasonal variances, annual recalculation, and/or other anticipated factors affecting staffed-bed capacity; and

(f) for hospitals with more than twenty-five (25) beds, a hospital's demonstrated ability to expand the hospital's staffed-bed capacity up to one hundred twenty-five (125) percent of the hospital's baseline staffed-bed capacity and intensive care unit (ICU) capacity within fourteen (14) days after the following:

(i) A statewide public health emergency is declared or the hospital is notified by the Department that surge capacity is needed; and

(ii) The state has used all available authority to expedite workforce availability and maximize hospital throughput and capacity, such as:

A. Licensing or certification flexibility for health facilities;

B. Reducing requirements for licensing, credentialing, and the receipt of staff privileges;

C. Waiving scope of practice limitations; and

D. Waiving state-regulated payer provisions that create barriers to timely patient discharge.

7.2 Each hospital shall comply with the requirements of 6 CCR 1009-5, Regulation 2 - Preparations by General or Critical Access Hospitals for an Emergency Epidemic.

6 CCR 1011-1 Chapter 04, pt. 7