| (9) evidence that the LSRH has communicated prospectively
with the local utility and phone companies regarding the need for
the LSRH to be given priority for the restoration of utility and phone
services and a process for testing internal and external communications
systems regularly.
(g) An LSRH shall post a phone number listing specific
to the LSRH equipment and locale to assist staff in contacting mechanical
and technical support in the event of an emergency.
(h) An LSRH must develop and maintain an emergency
preparedness training and testing program that is based on the emergency
plan set forth in subsection (a) of this section, risk assessment
in subsection (a)(1) of this section, policies and procedures in subsection
(E) of this section, and the communication plan in subsection (f)
of this section. The LSRH shall review and update the training and
testing program at least every two years.
(1) The LSRH shall:
(A) provide initial training in emergency preparedness
policies and procedures to all new and existing staff, individuals
providing on-site services under arrangement, and volunteers, consistent
with their expected roles;
(B) provide emergency preparedness training at least
every two years;
(C) maintain documentation of all emergency preparedness
training;
(D) demonstrate staff knowledge of emergency procedures;
and
(E) conduct training on the updated policies and procedures
if the LSRH significantly updates the emergency preparedness policies
and procedures.
(2) The LSRH shall conduct exercises to test the emergency
plan at least annually. The LSRH shall comply with all of the following
requirements.
(A) The LSRH shall participate in a full-scale exercise
that is community-based every two years.
(i) When a community-based exercise is not accessible,
the LSRH shall conduct an LSRH-based functional exercise every two
years; or
(ii) If the LSRH experiences an actual natural or man-made
emergency that requires activation of the emergency plan, the LSRH
is exempt from engaging in its next required community-based or individual,
facility-based functional exercise following the onset of the emergency
event.
(B) The LSRH shall conduct an additional exercise at
least every two years, opposite the year the LSRH conducts the full-scale
or functional exercise under subparagraph (A) of this paragraph, that
may include the following:
(i) a second full-scale exercise that is community-based,
or an individual, facility-based functional exercise;
(ii) a mock disaster drill; or
(iii) a tabletop exercise or workshop that is led by
a facilitator and includes a group discussion using a narrated, clinically
relevant emergency scenario, and a set of problem statements, directed
messages, or prepared questions designed to challenge an emergency
plan.
(C) The LSRH shall analyze the LSRH's response to and
maintain documentation of all drills, tabletop exercises, and emergency
events and revise the LSRH's emergency plan, as needed.
(3) An LSRH participating in an exercise or responding
to a real-life event shall develop an after-action report (AAR) within
60 days after the exercise or event. The LSRH shall retain an AAR
for at least three years and be available for review by the local
emergency management authority and HHSC. The LSRH shall revise the
LSRH's emergency plan, as needed, in response to the AAR.
(i) An LSRH must implement emergency and standby power
systems based on the emergency plan set forth in subsection (a) of
this section.
(1) The generator shall be located in accordance with
the location requirements found in the Health Care Facilities Code
(National Fire Protection Association (NFPA) 99 and Tentative Interim
Amendments (TIA) 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6),
Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1,
TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure
is built or when an existing structure or building is renovated.
(2) The LSRH shall implement emergency power system
inspection and testing requirements found in the Health Care Facilities
Code, NFPA 110, and the Life Safety Code.
(3) An LSRH that maintains an onsite fuel source to
power emergency generators must have a plan for how it will keep emergency
power systems operational during the emergency unless it evacuates.
(j) When an LSRH is part of a health care system consisting
of multiple separately certified health care facilities that elects
to have a unified and integrated emergency preparedness program, the
LSRH may choose to participate in the health care system's coordinated
emergency preparedness program. If elected, the unified and integrated
emergency preparedness program shall:
(1) demonstrate that each separately certified facility
within the system actively participated in the development of the
unified and integrated emergency preparedness program;
(2) be developed and maintained in a manner that takes
into account each separately certified facility's unique circumstances,
patient populations, and services offered;
(3) demonstrate that each separately certified facility
is capable of actively using the unified and integrated emergency
preparedness program and is in compliance;
(4) include a unified and integrated emergency plan
that meets the requirements of this section and include the following:
(A) a documented community-based risk assessment, utilizing
an all-hazards approach; and
(B) a documented individual facility-based risk assessment
for each separately certified facility within the health system, utilizing
an all-hazards approach; and
(5) include integrated policies and procedures that
meet the requirements set forth in subsection (e) of this section,
and a coordinated communication plan and training and testing programs
that meet the requirements of subsections (f) and (h) of this section,
respectively.
(k) The following material listed in this subsection
is incorporated by reference into this section.
(1) NFPA 99, Health Care Facilities Code, 2012 edition,
issued August 11, 2011.
(2) TIA 12-2 to NFPA 99, issued August 11, 2011.
(3) TIA 12-3 to NFPA 99, issued August 9, 2012.
(4) TIA 12-4 to NFPA 99, issued March 7, 2013.
(5) TIA 12-5 to NFPA 99, issued August 1, 2013.
(6) TIA 12-6 to NFPA 99, issued March 3, 2014.
(7) NFPA 101, Life Safety Code, 2012 edition, issued
August 11, 2011.
(8) TIA 12-1 to NFPA 101, issued August 11, 2011.
(9) TIA 12-2 to NFPA 101, issued October 30, 2012.
(10) TIA 12-3 to NFPA 101, issued October 22, 2013.
(11) TIA 12-4 to NFPA 101, issued October 22, 2013.
(12) NFPA 110, Standard for Emergency and Standby Power
Systems, 2010 edition, including TIAs to chapter 7, issued August
6, 2009.
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