Kan. Admin. Regs. § 26-52-12 - Emergency plan; safety; security

(a) Emergency plan. Each licensee shall develop and implement an emergency plan to provide for the safety of patients, staff members, volunteers, and visitors in emergencies.

(1) The emergency plan shall include the following information:

(A) Input from local emergency response entities, including fire departments, law enforcement, and local health care providers;

(B) the types of emergencies likely to occur in the center or near the center, including fire, weather-related events, elopement of patients, chemical releases, utility failure, loss of heating or air conditioning, intruders, computer system failure, and an unscheduled closing;

(C) the types of emergencies that could require evacuating the center and the types that could require patients, staff members, volunteers, and visitors to shelter in place;

(D) participation in community practice drills for emergencies;

(E) procedures to be followed by staff members in each type of emergency;

(F) designation of a staff member on each shift to be responsible for each of the following:

(i) Communicating with emergency response resources, including the fire department, law enforcement, and local health care providers;

(ii) ensuring that all patients, staff members, volunteers, and visitors are accounted for;

(iii) taking the emergency contact numbers and a cell phone;

(iv) accessing back-up systems, as needed, to obtain patient legal documentation, patient medical records and medication administration records; and

(v) contacting the legal guardian of each patient.

(G) the location and means of reaching a shelter-in-place area in the center, including safe movement of any patient, staff member, volunteer, or visitor with special health care or mobility needs; and

(H) the location and means of reaching an emergency site if evacuating the center, including the following:

(i) Entering into a written agreement with an emergency site for use as a temporary shelter for patients pending each patient's discharge pursuant to K.S.A. 59-29c08, and amendments thereto, and reviewing the written agreement with the emergency site for any necessary revisions at least once every three years;

(ii) safely transporting the patients, including patients with special health care or mobility needs to the emergency site;

(iii) transporting emergency supplies, including water, food, medication, clothing, and blankets to the emergency site;

(iv) providing necessary staffing and security for patients while using the emergency site;

(v) obtaining emergency medical care; and

(vi) complying with the evaluation and discharge requirements established by K.S.A. 59-29c08, and amendments thereto, while patients are being cared for at the emergency site.

(2) The emergency plan shall be kept on file in the center. The written agreement with the emergency site and any written agreement for pre-arranged transportation services for transporting patients to the emergency site shall be kept on file with the emergency plan.

(3) Each staff member shall be informed of and shall follow the emergency plan.

(4) The emergency plan shall be reviewed annually.

(5) Emergency call information shall be posted in a conspicuous location accessible by staff for the fire and police departments, an ambulance service, and the poison control center. Other emergency call information, including the names and telephone numbers of staff members to be notified in case of emergency, shall be kept on file in the center.

(6) The location of the shelter-in-place area or an emergency site and the means of reaching that area if evacuation is required shall be posted in a conspicuous place in the staff area of the center.

(b) Emergency exits.

(1) Each licensee shall develop and implement a plan for evacuation of patients, staff members, volunteers, and visitors, including evacuation routes and procedures, in case of fire or other emergencies. The licensee shall establish evacuation routes and post them in conspicuous patient, staff, and visitor areas throughout the center. Each licensee shall provide emergency electric service in the case of a power outage to all the following:

(A) Exit lights;

(B) exit corridor lighting;

(C) illumination of means of egress; and

(D) fire detection and alarm systems.

(2) Each staff member shall receive training on their duties and responsibilities for the reporting of an emergency, and evacuation of patients, staff, volunteers, and visitors in case of fire or other emergencies. Each staff member shall receive training on use of the fire alarm system or other notification system used in an emergency. Each staff member shall receive training on the proper use and the location of fire extinguishers.

(3) After admission, each patient shall receive information on the nearest evacuation route for use in case of a fire and an alternative route if the primary escape route is blocked.

(c) Fire drills. Each licensee shall conduct a fire drill at least quarterly. Fire drills shall be scheduled at a time when patients can participate. The date, time, number of participants, and duration of each drill shall be recorded and kept on file at the center for one calendar year.

(d) Tornado drills. Each licensee shall conduct a tornado drill at least quarterly. Tornado drills shall be scheduled at a time when patients can participate. The date, time, number of participants, and duration of each drill shall be recorded and kept on file at the center for one calendar year.

(e) Direct supervision and reporting. Each licensee shall implement policies and procedures that include the use of a combination of direct supervision, inspection, and accountability to promote safe and orderly operations. The policies and procedures shall be developed with input from local law enforcement and shall include all the following requirements:

(1) Written shift assignments shall designate the general duties and responsibilities for each staff member on duty at the center on each shift and shall provide the contact information for each professional staff member on call for each shift.

(2) A permanent log and a shift report prepared and maintained by supervisory staff members shall document routine and emergency situations that occur in the center each shift.

(3) Security devices, including locking mechanisms on doors and any delayed-exit mechanisms on doors, shall have current written approval from the state fire marshal and shall be regularly inspected and maintained, with any corrective action completed as necessary and recorded.

(4) The use of mace, pepper spray, and other chemical agents shall be prohibited.

(5) Patients shall not have access to any weapons.

(6) Provisions shall be made for the control and use of keys, tools, medical supplies, and culinary equipment.

(7) No patient shall have access to any keys for any door, cabinet, closet, or other device located in the center.

(8) Plans shall be developed for handling patient elopements, including accounting for the location of all patients when a patient cannot be located, and accounting for all staff, volunteers and visitors, and proper reporting when a patient elopement is suspected.

(9) Procedures shall be made for safety and security precautions pertaining to any vehicles used to transport patients, including accounting for, and securing keys to the center's vehicles.

(10) Procedures shall provide for the prompt reporting of any illegal act committed in the center.

(11) Procedures shall provide for the control of prohibited items and goods, including the screening and searches of patients and visitors and searches of rooms, spaces, and belongings.

(12) Procedures shall provide for the documentation and reporting of all critical incidents as required by this article.

(f) Storage and use of hazardous substances and unsafe items. Each licensee shall establish and implement procedures for the storage and use of hazardous substances and unsafe items, including the following requirements:

(1) No patient shall have unsupervised access to poisons, hazardous substances, or flammable materials. These items shall be kept in locked storage when not in use.

(2) Provisions shall be made for the safe and sanitary storage and distribution of personal care and hygiene items. The following items shall be stored in an area that is locked or under the control of staff members:

(A) Aerosols;

(B) alcohol-based products;

(C) any products in glass containers; and

(D) razors, blades, and any other sharp items.

(3) Policies and procedures shall be developed and implemented for the safe storage and disposal of prescription and nonprescription medications.

(A) All prescription and nonprescription medications shall be stored in a locked cabinet located in a designated area accessible to and supervised by staff members only.

(B) All refrigerated medications shall be stored in a locked refrigerator, in a refrigerator in a locked room, or in a locked medicine box in a refrigerator located in a designated area accessible to and supervised by staff members only.

(C) Medications taken internally shall be kept separate from other medications.

(D) Appropriate policies and procedures shall be developed and implemented to require documentation of medication administered to each patient, tracking of unused medication, and prompt discovery of any missing controlled substances.

(E) All unused medications shall be accounted for and disposed of in a safe manner by one of the following methods:

(i) Returning medication to the pharmacy;

(ii) sending medication with the patient upon their discharge from the center; or

(iii) safely discarding the medication.

(4) Each center shall have first-aid supplies, which shall be stored in a locked cabinet located in a designated area accessible to and supervised by staff members only.

Notes

Kan. Admin. Regs. § 26-52-12

Authorized by and implementing K.S.A. 39-2004; effective, T-26-2-16-24, Feb. 16, 2024; effective, T-26-6-10-24, June 10, 2024; adopted by Kansas Register Volume 43, No. 24; effective 6/28/2024.