SECTION 511.68. Emergency Preparedness

(a) A limited services rural hospital (LSRH) shall develop, adopt, implement, enforce, and maintain a written emergency preparedness plan. The LSRH shall review and update the plan at least every two years. The plan shall:

(1) be based on and include a documented, facility-based and community-based risk assessment, using an all-hazards approach;

(2) include strategies for addressing emergency events identified by the risk assessment;

(3) identify the services the LSRH has the ability to provide in an emergency and include strategies for addressing and serving the patient population;

(4) include the use of a Texas Health and Human Services Commission (HHSC)-approved process to update patient station availability as requested by HHSC during a public health emergency or state-declared disaster;

(5) include continuity of operations, including delegations of authority and succession plans;

(6) include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation; and

(7) incorporate applicable information listed in subsection (e) of this section and the State of Texas Emergency Management Plan. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator.

(b) An LSRH shall send the plan, which may be subject to review and approval by HHSC, to the local disaster management authority.

(c) The LSRH shall develop the plan through a joint effort of the LSRH governing body, administration, medical staff, LSRH personnel, and emergency medical services partners.

(d) An LSRH shall have an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure.

(e) An LSRH shall develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in subsection (a) of this section, risk assessment at subsection (a)(1) of this section, and the communication plan at subsection (f) of this section. The LSRH shall review and update the policies and procedures at least every two years. The policies and procedures shall at least address the following:

(1) reception, treatment, and disposition of casualties that can be used if a disaster situation requires the LSRH to accept multiple patients;

(2) the process, developed in conjunction with appropriate agencies, for allowing essential health care workers and personnel to safely access their delivery care sites;

(3) providing subsistence needs throughout the duration of the response for staff, volunteers, and patients, whether they evacuate or shelter in place, including:

(A) food, water, medical and pharmaceutical supplies, personal protection equipment, and appropriate immunizations;

(B) alternate sources of power to maintain:

(i) temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

(ii) emergency lighting;

(iii) fire detection, extinguishing, and alarm systems; and

(iv) sewage and waste disposal; and

(C) a system to track the location of on-duty staff and sheltered patients in the LSRH's care during an emergency, which also requires the LSRH to document the specific name and location of the receiving facility or other location when on-duty staff or sheltered patients are relocated during the emergency;

(4) safe evacuation from the LSRH, which includes the following:

(A) activation procedures, including who makes the decision to activate and how it is activated;

(B) consideration of care and treatment needs of evacuees;

(C) staff responsibilities;

(D) plan for the order of removal of patients and planned route of movement;

(E) transportation of staff, volunteers, and patients;

(F) records and supplies transportation, including the protocol for transferring patient-specific medications and records to the receiving facility, which requires records to include at a minimum:

(i) the patient's most recent physician assessment if seen by a physician;

(ii) the most recent assessment if the patient was last assessed by a practitioner within the scope of their license and education;

(iii) the order sheet;

(iv) medication administration record (MAR); and

(v) patient history with physical documentation;

(G) a weather-proof patient identification wrist band (or equivalent identification) must be intact on all patients;

(H) identification of any evacuation locations and destinations, including protocol to ensure the patient destination is compatible to patient acuity and health care needs; and

(I) primary and alternate means of communication with external sources of assistance;

(5) a means to shelter in place for patients, staff, and volunteers who remain in the LSRH;

(6) a system of medical documentation that does the following:

(A) preserves patient information;

(B) protects confidentiality of patient information; and

(C) secures and maintains the availability of records;

(7) the use of volunteers in an emergency and other staffing strategies, including the process and role for integration of state and federally designated health care professionals to address surge needs during an emergency; and

(8) An LSRH's emergency preparedness policies and procedures shall include the LSRH's role in providing care and treatment at an alternate care site identified by federal and local emergency management officials, in the event of a declared disaster or national emergency in accordance with federal rules, regulations, and associated waivers.

(f) An LSRH must develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. The LSRH shall review and update the communication plan at least every two years. The communication plan shall include:

(1) names and contact information for:

(A) staff;

(B) entities providing services under arrangement;

(C) patients' physicians; and

(D) volunteers;

(2) contact information for:

(A) federal, state, tribal, regional, and local emergency preparedness staff, including the city and county emergency management officers;

(B) the LSRH water supplier; and

(C) other sources of assistance;

(3) primary and alternate means for communicating with:

(A) LSRH staff; and

(B) federal, state, tribal, regional, and local emergency management agencies;

(4) procedures for notifying each of the following entities, as soon as practicable, regarding the closure or reduction in hours of operation of the LSRH due to an emergency:

(A) HHSC;

(B) each hospital with which the facility has a transfer agreement in accordance with §511.66 of this subchapter (relating to Patient Transfer Agreements);

(C) the trauma service area regional advisory council that serves the geographic area in which the facility is located; and

(D) each applicable local emergency management agency;

(5) a method for sharing information and medical documentation for patients under the LSRH's care, as necessary, with other health care providers to maintain the continuity of care;

(6) a means, in the event of an evacuation, to notify a patient's emergency contact or contacts of an evacuation and the patient's destination and release patient information as permitted under Code of Federal Regulations Title 45 (45 CFR) §164.510(b)(1)(ii) (relating to Uses and Disclosures Requiring an Opportunity for the Individual to Agree or to Object);

(7) a means of providing information about the general condition and location of patients under the LSRH's care as permitted under 45 CFR §164.510(b)(4);

(8) a means of providing information about the LSRH's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee; and

(9) evidence that the LSRH has communicated prospectively with the local utility and phone companies regarding the need for the LSRH to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly.

(g) An LSRH shall post a phone number listing specific to the LSRH equipment and locale to assist staff in contacting mechanical and technical support in the event of an emergency.

(h) An LSRH must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in subsection (a) of this section, risk assessment in subsection (a)(1) of this section, policies and procedures in subsection (E) of this section, and the communication plan in subsection (f) of this section. The LSRH shall review and update the training and testing program at least every two years.

(1) The LSRH shall:

(A) provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles;

(B) provide emergency preparedness training at least every two years;

(C) maintain documentation of all emergency preparedness training;

(D) demonstrate staff knowledge of emergency procedures; and

(E) conduct training on the updated policies and procedures if the LSRH significantly updates the emergency preparedness policies and procedures.

(2) The LSRH shall conduct exercises to test the emergency plan at least annually. The LSRH shall comply with all of the following requirements.

(A) The LSRH shall participate in a full-scale exercise that is community-based every two years.

(i) When a community-based exercise is not accessible, the LSRH shall conduct an LSRH-based functional exercise every two years; or

(ii) If the LSRH experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LSRH is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the emergency event.

(B) The LSRH shall conduct an additional exercise at least every two years, opposite the year the LSRH conducts the full-scale or functional exercise under subparagraph (A) of this paragraph, that may include the following:

(i) a second full-scale exercise that is community-based, or an individual, facility-based functional exercise;

(ii) a mock disaster drill; or

(iii) a tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(C) The LSRH shall analyze the LSRH's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the LSRH's emergency plan, as needed.

(3) An LSRH participating in an exercise or responding to a real-life event shall develop an after-action report (AAR) within 60 days after the exercise or event. The LSRH shall retain an AAR for at least three years and be available for review by the local emergency management authority and HHSC. The LSRH shall revise the LSRH's emergency plan, as needed, in response to the AAR.

(i) An LSRH must implement emergency and standby power systems based on the emergency plan set forth in subsection (a) of this section.

(1) The generator shall be located in accordance with the location requirements found in the Health Care Facilities Code (National Fire Protection Association (NFPA) 99 and Tentative Interim Amendments (TIA) 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

(2) The LSRH shall implement emergency power system inspection and testing requirements found in the Health Care Facilities Code, NFPA 110, and the Life Safety Code.

(3) An LSRH that maintains an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency unless it evacuates.

(j) When an LSRH is part of a health care system consisting of multiple separately certified health care facilities that elects to have a unified and integrated emergency preparedness program, the LSRH may choose to participate in the health care system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program shall:

(1) demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program;

(2) be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered;

(3) demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance;

(4) include a unified and integrated emergency plan that meets the requirements of this section and include the following:

(A) a documented community-based risk assessment, utilizing an all-hazards approach; and

(B) a documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach; and

(5) include integrated policies and procedures that meet the requirements set forth in subsection (e) of this section, and a coordinated communication plan and training and testing programs that meet the requirements of subsections (f) and (h) of this section, respectively.

(k) The following material listed in this subsection is incorporated by reference into this section.

(1) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.

(2) TIA 12-2 to NFPA 99, issued August 11, 2011.

(3) TIA 12-3 to NFPA 99, issued August 9, 2012.

(4) TIA 12-4 to NFPA 99, issued March 7, 2013.

(5) TIA 12-5 to NFPA 99, issued August 1, 2013.

(6) TIA 12-6 to NFPA 99, issued March 3, 2014.

(7) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.

(8) TIA 12-1 to NFPA 101, issued August 11, 2011.

(9) TIA 12-2 to NFPA 101, issued October 30, 2012.

(10) TIA 12-3 to NFPA 101, issued October 22, 2013.

(11) TIA 12-4 to NFPA 101, issued October 22, 2013.

(12) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.

Source Note: The provisions of this §511.68 adopted to be effective October 5, 2023, 48 TexReg 5668