|(a) Safety committee. Each facility shall have a multi-disciplinary
safety committee. The facility chief executive officer (CEO) shall
appoint the chairman and members of the safety committee.
(1) Safety officer. The CEO shall appoint a safety
officer who is knowledgeable in safety practices in health care facilities.
The safety officer shall be a member of the safety committee, and
shall carry out the functions of the safety program.
(2) Safety committee meetings. The safety committee
shall meet as required by the chairman, but not less than quarterly.
Written minutes of each meeting shall be retained for a period of
not less than one year.
(3) Safety activities.
(A) Incident reports. The safety committee shall
establish an incident reporting system which includes a mechanism
to ensure that all incidents recorded in safety committee minutes
are evaluated, and documentation is provided to show follow-up and
(B) Safety policies and procedures. The facility shall
develop, implement and enforce safety policies and procedures for
each department or service which are integrated within the overall
plan. Unit specific policies and procedures shall be maintained within
each department or service.
(C) Safety training and continuing education. Safety
training shall be established as part of new employee orientation
and in the continuing education of all employees.
(4) Written authority. The authority of the safety
committee to take action when conditions exist that are a possible
threat to life, health, or building damage, shall be defined in writing
and approved by the governing body.
(b) Emergency preparedness.
(1) Disaster management. Each facility shall develop
plans for effective preparedness, mitigation, response, and recovery
(2) Disaster preparedness. Each facility shall develop
a written policy and procedures for the following:
(A) notification of personnel and patients;
(B) the receipt, treatment and disposition of casualties;
(C) the identification of appropriate community resources;
(D) evacuation procedures.
(3) Disaster plans. National Fire Protection Association
99, Standard for Health Care Facilities, 1999 edition, Chapter 11,
and the State of Texas Emergency Management Planshall be used as references
to plan and establish the disaster plans. All documents published
by National Fire Protection Association (NFPA) as referenced in this
section may be obtained by writing or calling the NFPA at the following
address or telephone number: National Fire Protection Association,
1 Batterymarch Park, Post Office Box 9101, Quincy, MA 02269-9101 or
(800) 344-3555. Information regarding the State of Texas Emergency
Management Plan is available from the city or county emergency management
(4) Annual rehearsal. The facility shall practice the
disaster plans at least one time per year and shall document the rehearsal
of the plans. Documentation of rehearsals for the last three years
shall be retained.
(c) Emergency communication system. An emergency communication
system shall be provided in each facility. The system shall be self-sufficient
and capable of operating without reliance on the building's service
or emergency power supply. Such system shall have the capability of
communicating with the available community or state emergency networks,
including police and fire departments.
|Source Note: The provisions of this §510.102 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469