| (a) Definitions. In this section:
(1) "emergency situation" means an impending or actual
situation that:
(A) interferes with normal activities of a facility
and its residents;
(B) may:
(i) cause injury or death to a resident or staff member
of the facility; or
(ii) cause damage to facility property;
(C) requires the facility to respond immediately to
mitigate or avoid the injury, death, damage or interference; and
(D) does not include a situation that arises from the
medical condition of a resident, such as cardiac arrest, obstructed
airway, or cerebrovascular accident;
(2) "plan" refers to a facility's emergency preparedness
and response plan; and
(3) "receiving facility" means a facility or location
that has agreed to receive the residents of another facility who are
evacuated due to an emergency situation.
(b) Administration. A facility must:
(1) develop and implement a written plan as described
in subsection (c) of this section;
(2) maintain a current printed copy of the plan in
a central location that is accessible to all staff at all times and
at a work station of each personnel supervisor who has responsibilities
under the plan;
(3) evaluate the plan to determine if information in
the plan needs to change:
(A) within 30 days after an emergency situation;
(B) due to remodeling or making an addition to the
facility; and
(C) at least annually;
(4) revise the plan within 30 days after information
in the plan changes; and
(5) maintain documentation of compliance with this
section.
(c) Emergency Preparedness and Response Plan. A facility's
plan must:
(1) include a risk assessment of all potential internal
and external emergency situations relevant to the facility's operations
and geographical area, such as a fire, failure of heating and cooling
systems, a power outage, a bomb threat, an explosion, a hurricane,
a tornado, a flood, extreme snow and ice conditions for the area,
a wildfire, terrorism, a hazardous materials accident, or a thunderstorm
with a risk for harm to persons or property;
(2) include a description of the facility's resident
population;
(3) include a section for each core function of emergency
management, as described in subsection (d) of this section, that is
based on a facility's decision to either shelter-in-place or evacuate
during an emergency situation;
(4) include a section for a fire safety plan that complies
with §554.326 of this chapter (relating to Safety Operations);
and
(5) include a section for self reporting incidents
that complies with subsection (f) of this section.
(d) Plan Requirements Regarding Eight Core Functions
of Emergency Management.
(1) Direction and control. The facility's plan must
contain a section for direction and control that:
(A) designates by name or title the emergency preparedness
coordinator (EPC), who is the facility staff person with the authority
to manage the facility's response to an emergency situation in accordance
with the plan, and includes the EPC's current phone number;
(B) designates by name or title the alternate EPC,
who is the facility staff person with the authority to act as the
EPC if the EPC is unable to serve in that capacity, and includes the
alternate EPC's current phone number;
(C) documents the name and contact information for
the local emergency management coordinator (EMC) for the area where
the facility is located, as identified by the office of the local
mayor or county judge;
(D) includes procedures for notifying the local EMC
of the execution of the plan;
(E) includes a plan for coordinating a staffing response
to an emergency situation; and
(F) includes a plan for guiding residents to a safe
location that is based on the type of emergency situation occurring
and a facility's decision to either shelter-in-place or evacuate during
an emergency situation.
(2) Warning. A facility's plan must contain a section
for warning that:
(A) describes how the EPC will be notified of an emergency
situation;
(B) identifies who the EPC will notify of an emergency
situation and when the notification will occur, including during off
hours, weekends, and holidays; and
(C) addresses monitoring local news and weather reports
regarding a disaster or potential disaster taking into consideration
factors such as geographic specific natural disasters, whether a disaster
is likely to be addressed or forecast in the reports, and the conditions,
natural or otherwise, that would cause staff to monitor news and weather
reports for a disaster.
(3) Communication. A facility's plan must contain a
section for communication that:
(A) identifies the facility's primary mode of communication
to be used during an emergency situation and the facility's alternate
mode of communication to be used in the event of power failure or
the loss of the facility's primary mode of communication in an emergency
situation;
(B) requires posting of the emergency contact number
for the local fire department, ambulance, and police on or near each
telephone in the facility in communities where a "911" emergency management
system is unavailable;
(C) includes procedures for maintaining a current list
of telephone numbers for residents' responsible parties;
(D) includes procedures for maintaining a current list
of telephone numbers for pre-arranged receiving facilities;
(E) includes procedures for maintaining a current list
of telephone numbers for the facility's staff;
(F) identifies the location of the lists described
in subparagraphs (C) through (E) of this paragraph and in subsection
(d)(1)(A) and (B) of this section;
(G) includes procedures to notify:
(i) facility staff about an emergency situation;
(ii) a receiving facility about an impending or actual
evacuation of residents; and
(iii) residents and residents' responsible parties
about an impending or actual evacuation;
(H) provides a method for a person to obtain resident
information during an emergency situation; and
(I) includes procedures for the facility to maintain
communication with:
(i) facility staff involved in an emergency situation;
(ii) a receiving facility; and
(iii) the driver of a vehicle transporting residents,
medication, records, food, water, equipment, or supplies during an
evacuation.
(4) Sheltering Arrangements. A facility's plan must
contain a section for sheltering arrangements that:
(A) includes procedures for implementing a decision
to shelter-in-place that includes:
(i) having access to medications, records, food, water,
equipment and supplies; and
(ii) sheltering facility staff involved in responding
to an emergency situation, and their family members, if necessary;
(B) includes procedures for notifying HHSC Regulatory
Services regional office for the area in which the facility is located
by telephone immediately after the EPC makes a decision to shelter-in-place:
(i) before, during, or after a hurricane or flood impacts
a facility, if the risk assessment identified a hurricane or flood
as a potential emergency situation; or
(ii) after any other type of emergency situation that
has caused property damage to a facility;
(C) includes procedures for accommodating evacuated
residents, if the facility serves as a receiving facility for a facility
that has evacuated.
(5) Evacuation. A facility's plan must contain a section
for evacuation that:
(A) identifies evacuation destinations and routes,
and includes a map that shows the destinations and routes;
(B) includes procedures for implementing a decision
to evacuate residents to a receiving facility;
(C) includes a current copy of an agreement with a
receiving facility, outlining arrangements for receiving residents
in the event of an evacuation, if the evacuation destination identified
in accordance with subparagraph (B) of this paragraph is a receiving
facility that is not owned by the same entity as the evacuating facility;
(D) includes procedures for:
(i) ensuring facility staff accompany evacuating residents;
(ii) ensuring that residents and facility staff present
in the building have been evacuated;
(iii) accounting for residents and facility staff after
they have been evacuated;
(iv) accounting for residents absent from the facility
at the time of the evacuation;
(v) releasing resident information in an emergency
situation to promote continuity of a resident's care;
(vi) contacting the local EMC to find out if it is
safe to return to the geographical area after an evacuation;
(vii) determining if it is safe to re-enter and occupy
the building after an evacuation; and
(E) includes procedures for notifying the local EMC
regarding an evacuation of the facility;
(F) includes procedures for notifying HHSC Regulatory
Services regional office for the area in which the facility is located
by telephone immediately after the EPC makes a decision to evacuate;
and
(G) includes procedures for notifying HHSC Regulatory
Services regional office for the area in which the facility is located
by telephone immediately when residents have returned to the facility
after an evacuation.
(6) Transportation. A facility's plan must contain
a section for transportation that:
(A) arranges for a sufficient number of vehicles to
safely evacuate all residents;
(B) identifies facility staff designated to drive a
facility owned, leased or rented vehicle during an evacuation;
(C) includes procedures for safely transporting residents,
facility staff involved in an evacuation; and
(D) includes procedures for safely transporting and
having timely access to oxygen, medications, records, food, water,
equipment, and supplies needed during an evacuation.
(7) Health and Medical Needs. A facility's plan must
contain a section for health and medical needs that:
(A) identifies the types of services used by residents,
such as dialysis, oxygen, respirator care, or hospice services; and
(B) ensures the resident's needs identified in subparagraph
(A) of this paragraph are met during an emergency situation.
(8) Resource Management. A facility's plan must contain
a section for resource management that:
(A) includes a plan for identifying medications, records,
food, water, equipment and supplies needed during an emergency situation;
(B) identifies facility staff who are assigned to locate
the items in subparagraph (A) of this paragraph and who must ensure
the transportation of the items during an emergency situation; and
(C) includes procedures to ensure medications are secure
and maintained at the proper temperature during an emergency situation.
(e) Training. The facility must:
(1) train a facility staff member on the staff member's
responsibilities under the plan within 30 days after assuming job
duties;
(2) train a facility staff member on the staff member's
responsibilities under the plan at least annually and when the staff
member's responsibilities under the plan change; and
(3) conduct one unannounced annual drill with facility
staff for severe weather and other emergency situations identified
by the facility as likely to occur, based on the results of the risk
assessment required by subsection (c)(1) of this section.
(f) Self-Reported Incidents.
(1) A facility must report a fire to HHSC as follows:
(A) by calling 1-800-458-9858 immediately after the
fire; and
(B) by submitting a completed HHSC form titled "Fire
Report for Long Term Care Facilities" within 15 calendar days after
the fire.
(2) A facility must report an emergency situation that
caused the death or serious injury of a resident to HHSC as follows:
(A) by calling 1-800-458-9858 immediately after the
death or serious injury; and
(B) by submitting a completed HHSC form titled "HHSC
Provider Investigation Report" within 5 working days after making
the telephone report required by paragraph (2)(A) of this subsection.
(g) Emergency Response System.
(1) The facility administrator and director of nursing
must enroll in an emergency communication system in accordance with
instructions from HHSC.
(2) The facility must respond to requests for information
received through the emergency communication system in the format
established by HHSC.
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