Utah Admin. Code R432-100-40 - Emergency Operations Plan

(1) The licensee shall have an emergency operations plan for the maintenance of a safe environment in the event of an emergency or disaster that overwhelms the facility.

(2) The administrator or designee is responsible for the development of the plan, coordinated with applicable state and local emergency response partners and agencies. The plan shall:

(a) be in writing and made available to any hospital staff;

(b) be reviewed and updated as necessary and be available for review by the department;

(c) delineate individuals who will be in charge in the event of any significant emergency;

(d) include readily available lists of emergency partners with multiple contact options, emergency contact lists are updated and maintained regularly by the licensee;

(e) delineate the person with decision-making authority to activate the emergency operations plan;

(f) address risks and threats identified in the licensee's annual hazard vulnerability analysis;

(g) have an evacuation plan;

(h) address delivery of essential care and services when additional persons are present at the hospital during an emergency;

(i) address delivery of essential care and services to hospital occupants utilizing crisis standards of care when staff is reduced by an emergency; and

(j) address planning, mitigation, response, and recovery for each of the following areas:

(i) emergency communications;

(ii) resources and assets;

(iii) safety and security;

(iv) staff responsibilities;

(v) utility management; and

(vi) patient clinical and supportive activities.

(3) The hospital administrator and the board shall approve the emergency operations plan.

(4) The licensee shall document any emergency incidents and responses.

(5) The licensee shall hold disaster drills or exercises twice yearly according to threats identified in the facility's annual hazard vulnerability analysis.

(6) The licensee shall have a fire emergency evacuation plan written in consultation with qualified fire safety personnel. This plan may be included in the facility's emergency operations plan.

(7) The licensee shall post evacuation routes posted in prominent locations throughout the hospital.

(8) The licensee shall document fire drills and ensure fire drill documentation is in accordance with Rule R710-4.

(9)

(a) A licensee may exceed its licensed capacity by up to 20% in response to any incident that overwhelms the facility.

(b) A hospital that exceeds its licensed capacity under this provision shall notify the department within 72 hours of exceeding its licensed capacity.

(c) The licensee shall seek department approval to exceed 20% above licensed capacity.

(d) The department may direct that the licensee reduce its patient census to its licensed capacity at any time.

Notes

Utah Admin. Code R432-100-40

Adopted by Utah State Bulletin Number 2016-5, effective 2/10/2016 Amended by Utah State Bulletin Number 2017-12, effective 5/16/2017 Amended by Utah State Bulletin Number 2023-14, effective 7/6/2023 Amended by Utah State Bulletin Number 2025-01, effective 12/27/2024