(1) All health care facilities must develop a written disaster plan as follows:
(a) skilled nursing facilities (long-term care), outpatient centers for primary care, outpatient centers for surgical services, critical access hospitals, hospitals, residential hospice facilities, inpatient hospice facilities, and infirmaries must develop a written disaster plan in conjunction with other emergency services in the community;
(b) these procedures must be developed such that they can be followed in the event of a natural or man-caused disaster.
(2) The health care facilities identified in (1) must conduct a review or physical exercise of such procedures at least once a year. After a review or exercise a health care facility shall prepare and retain on file for a minimum of three years a written report including but not limited to the following:
(a) date and time of the review or exercise;
(b) the names of staff involved in the review or exercise;
(c) the names of other health care facilities, if any, which were involved in the review or exercise;
(d) the names of other persons involved in the review or exercise;
(e) a description of all phases of the procedure and suggestions for improvement; and
(f) the signature of the person conducting the review or exercise.
(3) Adult day care facilities, adult foster care homes, assisted living facilities, chemical dependency treatment centers, end-stage renal dialysis facilities, intermediate care facilities for the developmentally disabled, mental health centers, outdoor behavioral facilities, residential treatment facilities, retirement homes, and specialty mental health facilities must develop a written disaster plan for their facility, and conduct a documented review of the disaster plan with all facility staff annually. This documentation must be maintained at the facility for a minimum of three years. The disaster plan must include:
(a) plans for remaining at the facility during and subsequent to the disaster. Plans must include such elements as acquisition of additional blankets, water, food, etc.; and
(b) plans for resident evacuation and identification of at least one off-site evacuation point. A written agreement must be maintained in the facility record and updated annually.
(4) Fire drills must be conducted at all health care facilities.
(a) health care facilities that house patients or residents must conduct at least four fire drills annually, no closer than two months apart, with at least one drill occurring on each shift. Drill observations must be documented and maintained at the facility for at least two years. The documentation must include:
(i) location of the drill;
(ii) documentation that identifies participating staff;
(iii) problems identified during the drill;
(iv) steps taken to correct such problems; and
(v) signature of the individual responsible for the day-to-day operation of the health care facility.