Section R432-101-16 - Emergency and Disaster(1) The licensee shall ensure the safety and well-being of patients and provide for a safe environment in the event of an emergency or disaster including utility interruption of gas, water, sewer, fuel or electricity, explosion, fire, earthquake, bomb threat, flood, windstorm, epidemic, and injury.(2) The administrator or designee shall develop a plan, coordinated with state and local emergency or disaster offices, to respond to emergencies or disasters that is: (a) documented in writing and lists the coordinating authorities by name and title;(b) distributed or made available to any hospital staff to ensure prompt and efficient implementation;(c) reviewed and updated as necessary in coordination with local emergency or disaster management authorities; and(d) available for review by the department.(3) The administrator shall take charge of operations during any significant emergency. If not on the premises, the administrator shall make every reasonable effort to get to the hospital to relieve subordinates and take charge of the situation.(4) The licensee shall hold and document the response to disaster drills, in addition to fire drills, on a semi-annual basis for staff.(5) The licensee shall identify and prominently post:(a) the name of the person in charge;(b) the names and telephone numbers of emergency medical personnel or agencies;(c) emergency transport systems; and(d) appropriate communication with the entities listed in this subsection.(6) The licensee shall ensure the emergency response procedures addresses the following: (a) evacuation of occupants to a safe place within the hospital or to another location;(b) delivery of essential care and services to hospital occupants by alternate means regardless of setting;(c) delivery of essential care and services when additional persons are housed in the hospital during an emergency;(d) delivery of essential care and services to hospital occupants when staff is reduced by an emergency; and(e) maintenance of safe ambient air temperatures within the hospital in accordance with Subsection 432-101-16(7).(7)(a) The licensee shall maintain an ambient temperature of 58 degrees Fahrenheit(F) or 14 degrees Celsius(C) within the hospital.(b) A temperature any lower than 58 degrees F or 14 degrees C may constitute a danger to the health and safety of the patients in the hospital and the person in charge shall take immediate and appropriate action when the temperature meets the minimum threshold.(c) The licensee shall ensure the local fire department approves emergency heating.(8) The licensee shall ensure the emergency plan delineates and includes: (a) the person with decision-making authority for fiscal, medical, and personnel management;(b) on-hand personnel, equipment, and supplies and instructions on how to acquire additional help, supplies, and equipment after an emergency or disaster;(c) assignment of personnel to specific tasks during an emergency;(d) methods of communicating with local emergency agencies, authorities, and other appropriate individuals;(e) the individuals to be notified in an emergency in order of priority;(f) method of transporting and evacuating patients and staff to other locations; and(g) conversion of hospital facilities for emergency use. (9)(a) The licensee shall schedule and hold at least one fire drill per shift per quarter and document the date and time the drill was held, including a brief description of the event and participants.(b) The evacuation of patients during a drill is optional(c) The licensee shall maintain documentation of fire drills for review by the department.(10)(a) The licensee shall have an emergency evacuation plan, written in consultation with qualified fire safety personnel.(b) The licensee shall post a physical plant evacuation diagram delineating evacuation routes, location of fire alarm boxes and fire extinguishers, and emergency telephone numbers of the local fire department in exit access ways throughout the hospital.(c) The written plan shall include fire-containment procedures and how to use the hospital alarm systems and signals.Utah Admin. Code R432-101-16
Amended by Utah State Bulletin Number 2023-22, effective 11/1/2023