R432-100-39. Emergency Operations Plan

  (1) There must be provisions for the maintenance of a safe environment in the event of an emergency or disaster which overwhelms the facility.

  (2) The administrator or designee is responsible for the development of a plan, coordinated with applicable state and local emergency response partners and agencies. This plan shall be in writing and made available to all hospital staff.

  (a) The plan shall be reviewed and updated as necessary and shall be available for review by the Department.

  (b) The hospitals' emergency operations plan must delineate individuals who will be in charge during any significant emergency.

  (c) Lists of emergency partners shall be readily available, including multiple contact options. Emergency contact lists will be updated and maintained regularly by the hospital.

  (3) The hospital's emergency operations plan shall address the following:

  (a) an evacuation plan;

  (b) delivery of essential care and services when additional persons are present at the hospital during an emergency;

  (c) delivery of essential care and services to hospital occupants utilizing crisis standards of care when staff is reduced by an emergency; and

  (d) must address planning, mitigation, response and recovery for each of the following six areas:

  (i) emergency communications;

  (ii) resources and assets;

  (iii) safety and security;

  (iv) staff responsibilities;

  (v) utility management; and

  (vi) patient clinical and supportive activities.

  (4) The emergency operations plan shall be approved by the board and the hospital administrator.

  (a) The hospital's emergency operations plan shall delineate the person or persons with decision-making authority to activate the emergency operations plan;

  (b) The hospital's emergency response plan shall address those risks and threats identified in the facility's annual hazard vulnerability analysis.

  (c) The hospital shall document all emergency incidents and responses.

  (d) Disaster drills/exercises shall be held twice yearly according to threats identified in the facility's annual hazard vulnerability analysis.

  (5) There shall be a fire emergency evacuation plan written in consultation with qualified fire safety personnel. This plan may or may not be included in the facility's emergency operations plan. The evacuation routes shall be posted in prominent locations throughout the hospital. Fire drills and fire drill documentation shall be in accordance with R710-4, State of Utah Fire Prevention Board.

  (6) A hospital may exceed its licensed capacity by up to 20% in response to any incident that overwhelms the facility.

  (a) A hospital which exceeds its licensed capacity under this provision shall notify the Department within 72 hours of exceeding its licensed capacity.

  (b) Approval must be obtained from the Department to exceed 20% above licensed capacity.

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