La. Admin. Code tit. 48 § I-9335

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-9335 - Emergency Preparedness

A. The hospital shall have an emergency preparedness plan designed to manage the consequences of natural disasters or other emergencies that disrupt the hospital's ability to provide care and treatment or threatens the lives or safety of the hospital patients and/or the community it serves. The emergency preparedness plan shall be made available, upon request or if mandated to do so, to local, parish, regional and/or state emergency planning organizations, LDH and the OSFM and shall include the four core elements of emergency preparedness:

1. comprehensive risk assessment and emergency planning of:

a. all hazards likely in geographic area;

b. care-related emergencies;

c. equipment and power failures;

d. interruption in communications, including cyber-attacks;

e. loss of all/portion of facility;

f. loss of all/portion of supplies; and

g. reviewed and updated at least every 2 years;

2. communication plan that:

a. complies with federal and state laws;

b. has a system to contact staff, including patients' physicians, other necessary persons; and

c. is well-coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies;

3. policies and procedures that comply with federal and state laws; and

4. training and testing that:

a. complies with federal and state laws; and

b. are maintained, reviewed, and updated at least every two years.

B. As a minimum, the plan shall include the following:

1. an all hazards risk assessment and identification of potential hazards that could necessitate an evacuation, including internal and external disasters such as a natural disaster, acts of bio-terrorism, weapons of mass destruction, labor work stoppage, or industrial or nuclear accidents;

2. emergency procedures for evacuation of the hospital;

3. comprehensive measures for receiving and managing care for a large influx of emergency patients. At a minimum, these measures shall include the following roles:

a. the emergency department/s ervices;

b. surgical suite; and

c. patient care units;

4. comprehensive plans for receiving patients who are being relocated from another facility due to a disaster. This plan shall include at least an estimate of the number and type of patients the facility would accommodate and current contact information for receiving hospitals and other facilities;

5. procedures in the case of interruption of utility services that address the provision of alternate sources of energy to maintain:

a. temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

b. emergency lighting; and

c. fire detection, extinguishing;

6. identification of the facility and an alternate facility to which evacuated patients would be relocated;

7. the estimated number of patients and staff that would require relocation in the event of an evacuation;

8. the system or procedure to ensure that medical charts accompany patients in the event of a patient evacuation and that supplies, equipment, records, and medications would be transported as part of an evacuation;

9. the roles and responsibilities of staff members in implementing the disaster plan; and

10. a system to track on-duty staff and sheltered patients during the emergency.

C. The hospital shall assure that patients receive nursing care throughout the period of evacuation and while being returned to the original hospital.

D. The hospital shall ensure that evacuated patients, who are not discharged, are returned to the hospital after the emergency is over, unless the patient prefers to remain at the receiving facility or be discharged instead of being returned to the original hospital.

E. Any staff member who is designated as the acting administrator shall be knowledgeable about, and authorized to implement the hospital's plans in the event of an emergency.

F. The hospital administrator shall appoint an individual who shall be responsible for disaster planning for the hospital.

G. While developing the hospital's plan for evacuating patients, the disaster planner shall communicate with the facility or facilities designated to receive relocated patients for development of a method for sharing information and medical documentation of evacuated patients.

H. The hospital shall conduct exercises to test the emergency plan twice per year. The hospital shall do all of the following:

1. Participate in a full-scale exercise that is community-based every two years or when a community-based exercise is not available, conduct an individual, facility based functional exercise every two years; or if the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.

2. Conduct an additional exercise at least every two years opposite the year the full-scale or functional exercise under number one above is conducted, that may include, but is not limited to the following:

a. a second full-scale exercise that is community-based or individual, facility-based functional exercise;

b. a mock disaster drill; or

c. a tabletop exercise or workshop that is led by a facilitator and includes a group discussion;

3. Analyze the hospital's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital's emergency plan as needed.

I. The hospital shall also conduct at least one drill each year, in which a large influx of emergency patients is simulated. An actual emergency of this type shall be considered a drill, if it is documented.

J. In case of an emergency, the hospital shall have a policy for supply of food and water.

K. The hospital shall have a policy for the provision of emergency sources (e.g., generators) of critical utilities such as electricity, natural gas, water and fuel during any period in which the normal supply is temporarily disrupted.

L. The hospital's plan shall be developed in coordination with the local/parish office of emergency preparedness, utilizing community wide resources.

M. A hospital may temporarily exceed its licensed capacity in emergency situations, such as during a declared emergency. Such hospitals shall notify LDH in writing of the situation within 24 hours or as soon as practical thereafter.

N. Effective immediately, upon declaration of the secretary and notification to the Louisiana Hospital Association, all hospitals licensed in Louisiana shall file an electronic report with the Mstat, or a successor emergency support function (ESF)-8 portal operating system during a declared emergency, disaster, or public health emergency.

1. The electronic report shall be filed once a day or in accordance with federal, state, and local statutes, regulations, and guidance throughout the duration of the disaster or emergency event or as directed by the department.

2. The electronic report shall include, but not be limited to the following:

a. status of operation (open, limited or closed);

b. availability of beds by category (medical/surgery, intensive care unit, pediatric, psychiatric, etc.);

c. other resources that may be needed by a hospital in an emergency (blood products, fuel, pharmaceuticals, personnel, etc.);

d. generator status;

e. evacuation status; and

f. shelter in place status.

La. Admin. Code tit. 48, § I-9335

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 21:177 (February 1995), amended LR 29:2409 (November 2003), LR 35:245 (February 2009), Amended by the Department of Health, Health Standards Section, LR 501483 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.