| (a) Safety committee. A limited services rural hospital
(LSRH) shall have a multidisciplinary safety committee. The LSRH 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.
The committee shall retain written minutes for each meeting for at
least one year.
(3) Safety activities.
(A) Incident reports. The safety committee shall establish
an incident reporting system that includes a mechanism to ensure that
all incidents recorded in safety committee minutes are evaluated,
and documentation is provided to show follow-up and corrective actions.
(B) Safety policies and procedures. Safety policies
and procedures for each department or service shall be developed,
implemented, and enforced.
(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) Safety manual. Each department or service shall
have a safety policy and procedure manual within their own area that
becomes a part of the overall facility safety manual.
(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.
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