No. 28311 (Amendment): R432-100-38. Emergency and Disaster Plan

DAR File No.: 28311
Filed: 10/31/2005, 04:19
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

In order to improve Utah's capabilities to respond and care for victims of a mass casualty incident or bioterrorism outbreak, a proposal was made to the Health Facility Committee to consider a modification of the Health Facility Licensing rules. The change would allow hospitals to increase their bed capacity by 20% in the event of a mass casualty incident, without a variance from the Department of Health. The Committee approved the proposal unanimously.

 

Summary of the rule or change:

One statement would be added to the existing hospital rule to allow any hospital to go above their licensed capacity by 20% in the case of a mass casualty event without obtaining a variance from the Department of Health.

 

State statutory or constitutional authorization for this rule:

Title 26, Chapter 21

 

Anticipated cost or savings to:

the state budget:

There will only be minor cost savings to the state budget. Since no variance would be needed to exceed capacity, it would save staff time in processing the paperwork. This could be as much as $35 per incident. Since there has not been any history with a mass casualty situation that required variances, no yearly savings is estimated.

 

local governments:

There are seven hospitals that are owned by local governments. They could see the same cost savings by not having to use staff time to apply for a variance. Since there is no history with mass casualty events and variances, the estimated savings is minimal.

 

other persons:

Hospitals could see the same cost savings by not having to use staff time to apply for a variance. Since there is no history with mass casualty events and variances, the estimated savings is minimal.

 

Compliance costs for affected persons:

There are no anticipated compliance costs for any parties as a result of this rulemaking. This rule amendment would only reduce the rule requirements that providers should follow, so there should only be cost savings for providers.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

In the event of a mass casualty event, this rule will provided critical flexibility for facilities to meet that need without having to apply for a variance. This should have a positive fiscal impact. David N. Sundwall, MD, Executive Director

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Systems Improvement, Licensing
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Joel Hoffman at the above address, by phone at 801-538-6165, by FAX at 801-538-6163, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/15/2005

 

This rule may become effective on:

12/16/2005

 

Authorized by:

David N. Sundwall, Executive Director

 

 

RULE TEXT

R432. Health, Health Systems Improvement, Licensing.

R432-100. General Hospital Standards.

R432-100-38. Emergency and Disaster Plan.

(1) The hospital is responsible to assure the safety and well-being of patients. There must be provisions for the maintenance of a safe environment in the event of an emergency or disaster. An emergency or disaster may include utility interruption such as gas, water, sewer, fuel or electricity interruption, explosion, fire, earthquake, bomb threat, flood, windstorm, epidemic, bio-terrorism event or mass casualty incident.

(2) The administrator or designee is responsible for the development of a plan, coordinated with state and local emergency or disaster offices, to respond to emergencies or disasters. This plan shall be in writing and list the coordinating authorities by agency name and title. The plan shall be distributed or made available to all hospital staff to assure prompt and efficient implementation.

(a) The plan shall be reviewed and updated as necessary in coordination with local emergency or disaster management authorities. The plan shall be available for review by the Department.

(b) The administrator or designee is in 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.

(c) The name of the person in charge and names and telephone numbers of emergency medical personnel, agencies and appropriate communication and emergency transport systems shall be readily available to all hospital staff.

(3) The hospital's emergency response procedures shall address 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.

(4) The hospital shall have an emergency plan that is current and appropriate to the operation and construction of the hospital. The plan shall be approved by the board and the hospital administrator.

(a) The hospital's emergency plan shall delineate:

(i) the person or persons with decision-making authority for fiscal, medical, and personnel management;

(ii) on-hand personnel, equipment, and supplies and how to acquire additional help, supplies, and equipment after an emergency or disaster;

(iii) assignment of personnel to specific tasks during an emergency;

(iv) methods of communicating with local emergency agencies, authorities, and other appropriate individuals;

(v) the telephone numbers of individuals to be notified in an emergency in order of priority;

(vi) methods of transporting and evacuating patients and staff to other locations; and

(vii) conversion of the hospital for emergency use.

(b) Emergency telephone numbers shall be accessible to staff at each nurses station.

(c) The hospital shall document emergency events and responses and record patients and staff evacuated from the hospital to another location. Any emergency involving patients shall be documented in the patient record.

(d) Simulated disaster drills shall be held semiannually for all staff. One disaster drill shall address a bio-terrorism or communicable disease event.

(e) Fire drills and fire drill documentation shall be in accordance with R710-4, State of Utah Fire Prevention Board.

(5) There shall be a fire emergency evacuation plan written in consultation with qualified fire safety personnel. The evacuation plan shall be posted in prominent locations throughout the hospital.

(6) A hospital may exceed its licensed capacity by up to 20% in response to a mass casualty event, or other unusual event, which causes a need for hospital beds that exceeds the current licensed hospital capacity of the affected geographic area.

(a) A hospital which exceeds its licensed capacity under this provision shall notify the Department within 72 hours of exceeding its licensed capacity. This notice shall be by fax or telephone call to the licensing agency.

(b) The Department may direct that the hospital reduce its patient census to its licensed capacity at any time.

 

KEY: health facilities

[November 10, 2004]2005

Notice of Continuation October 16, 2002

26-21-5

26-21-2.1

26-21-20