Tenn. Comp. R. & Regs. 1200-08-01-.14 - DISASTER PREPAREDNESS

(1) Emergency Electrical Power.
(a) All hospitals must have one or more on-site electrical generators which are capable of providing emergency electrical power to at least all life sustaining equipment and life sustaining resources such as: ventilators; blood banks, biological refrigerators, safety switches for boilers, safety lighting for corridors and stairwells and other essential equipment.
(b) Connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. (It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source).
(c) The emergency power system shall have a minimum of twenty four (24) hours of either propane, natural gas, gasoline or diesel fuel. The quantity shall be based on its expected or known connected load consumption during power interruptions. In addition, the hospital shall have a written contract with an area fuel distributor which guarantees first priority service for re-fills during power interruptions.
(d) The emergency power system shall be inspected weekly and exercised and under actual load and operating temperature conditions for at least thirty (30) minutes, once each month. Records shall be maintained for all inspections and tests and kept on file for a minimum of three (3) years.
(2) Physical Facility and Community Emergency Plans.
(a) Physical Facility (Internal Situations).
1. Every hospital shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high risk situations such as floods, earthquakes, toxic fumes and chemical spills.
2. The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Plans that provide for the relocation of patients to other health care facilities must have written agreements for emergency transfers. Their agreements may be mutual, i.e. providing for transfers either way.
3. Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to all staff. Provisions that have security implications may be omitted from the outline versions. Familiarization information shall be included in employee orientation sessions and more detailed instructions must be included in continuing education programs. Records of orientation and education programs must be maintained for at least three (3) years.
4. Drills of the disaster preparedness plan shall be conducted at least once a year. The risk focus may vary by type of drill. Drills are for the purpose of educating staff, resource determination, testing personal safety provisions and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.
5. As soon as possible, real situations that result in a response by local authorities must be documented. This includes a critique of the activation of the plan. Actual documented situations that had education and training value may be substituted for a drill.
(b) Community Emergency (Mass Casualty).
1. Every hospital, unless exempted due to its limited scope of clinical services, shall have a plan that provides for the reception and treatment, within its capabilities, of medical emergencies resulting from a disaster within its usual service area. The plan should consider the probability of the types of disasters which might occur, both natural and "man-made".
2. The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed. The plan must also include for the deferral of elective admission patients and also for the early transfer or discharge of some current patients if it appears that the number of casualties will exceed available staffed beds.
3. Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to staff who would be assigned non-routine duties during these types of emergencies. Familiarization information shall be included in employee orientation sessions and more detailed instruction must be included in continuing education programs. Records of orientation and education must be maintained for at least three (3) years.
4. At least one drill shall be conducted each year for the purpose of educating staff, resource determination, and communications with other facilities and community agencies. Records which document and evaluate these drills must be maintained for at least three (3) years.
5. As soon as possible, actual community emergency situations that result in the treatment of more than twenty (20) patients, or fifteen percent (15%) of the licensed bed capacity, whichever is less, must be documented. Actual situations that had education and training value may be substituted for a drill. This includes documented actual plan activation during community emergencies, even if no patients are received.
(c) Emergency Planning with Local Government Authority.
1. All hospitals shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The facility shall cooperate, to the extent possible, in area disaster drills and local emergency situations.
2. Each hospital must rehearse both the Physical Facility and Community Emergency plan as required in these regulations, even if the local Emergency Management Agency is unable to participate.
3. A file of documents demonstrating communications and cooperation with the local agency must be maintained.

Notes

Tenn. Comp. R. & Regs. 1200-08-01-.14
Original rule filed March 18, 2000; effective May 30, 2000.

Authority: T.C.A. ยงยง 4-5-202, 68-11-202, 68-11-204, 68-11-206, 68-11-209, and 68-11-216.

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