1. (1) The REH shall develop and implement a comprehensive plan that complies with all applicable federal, state, and local emergency preparedness requirements to ensure that the safety and wellbeing of patients are assured during emergency situations. An REH's emergency preparedness plan must include provisions for emergency preparedness, risk assessment, communication, and an emergency preparedness training and testing program. All aspects of the plan must be reviewed and updated at least every 2 years and meet the emergency preparedness requirements of the Board's Rules for Hospitals, Chapter 420-5-7, Ala. Admin. Code.

2. (2) At a minimum, the policies and procedures must address the following:

   1. (a) The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to:

      1. 1. Food, water, medical, and pharmaceutical supplies; and

      2. 2. Alternate sources of energy to maintain:

         1. (i) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;
         2. (ii) Emergency lighting.
         3. (iii) Fire detection, extinguishing, and alarm systems; and
         4. (iv) Sewage and waste disposal.
            
            
   2. (b) A system to track the location of on-duty staff and sheltered patients in the REH's care during an emergency.  If on-duty staff or sheltered patients are relocated during the emergency, the REH must document the specific name and location of the receiving facility or other location.

   3. (c) Safe evacuation from the REH, which includes the following:

      1. 1. Consideration of care and treatment needs of evacuees.
      2. 2. Staff responsibilities.
      3. 3. Transportation.
      4. 4. Identification of evacuation location(s), and
      5. 5. Primary and alternate means of communication with external sources of assistance.
   4. (d) A means to shelter in place for patients, staff, and volunteers who remain in the REH.

   5. (e) A system of medical documentation that does the following:

      1. 1. Preserves patient information.
      2. 2. Protects confidentiality of patient information, and
      3. 3. Secures and maintains the availability of records.
   6. (f) 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.
   7. (g) The role of the REH under a waiver declared by the U.S. Secretary of Health and Human Services and, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
      
      

3. (3) The REH must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth hereinabove. The REH must do all of the following:

   1. (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.
   2. (b) Provide emergency preparedness training at least every 2 years.
   3. (c) Maintain documentation of all emergency preparedness training.
   4. (d) Demonstrate staff knowledge of emergency procedures.
   5. (e) If the emergency preparedness policies and procedures are significantly updated, the REH must conduct training on the updated policies and procedures.

4. (4) The REH must conduct exercises to test the emergency plan at least annually. The REH must do the following:

   1. (a) Participate in a full-scale exercise that is community-based every 2 years.

      1. 1. When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
      2. 2. If the REH experiences an actual natural or man-made emergency that requires activation of the emergency plan, the REH is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the emergency event.

   2. (b) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following:
      
      

      1. 1. A second full-scale exercise that is community-based, or an individual, facility-based functional exercise; or
      2. 2. A mock disaster drill; or
      3. 3. 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.
   3. (c) Analyze the REH's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the REH's emergency plan, as needed.

5. (5) The REH must implement emergency and standby power systems based on the emergency plan.
   
   

   1. (a) The emergency generator must be located in accordance with the location requirements found in the Health Care Facilities Code (National Fire Protection Association (NFPA) 99 and Technical Interim Amendments (TIA) 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and 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. (b) The REH must implement emergency power system inspection and testing requirements found in the Health Care Facilities Code, NFPA 110, and the Life Safety Code.
   3. (c) REHs that maintain 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.

6. (6) If an REH is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the REH may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must:

   1. (a) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.
   2. (b) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.
   3. (c) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance.

Author: Dana H. Billingsley

Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.

History: New Rule: Published August 31, 2023; effective October 15, 2023.