1. A. An administrator shall ensure that:

   1. 1. A disaster plan is developed, documented, maintained in a location accessible to personnel members and other employees, and, if necessary, implemented that includes:

      1. a. A floor plan of the facility showing emergency protection equipment, evacuation routes, and exits;

      2. b. When, how, and where residents will be relocated, including:

         1. i. Instructions for the evacuation or transfer of residents,
         2. ii. Assigned responsibilities for each employee and personnel member, and
         3. iii. A plan for continuing to provide services to meet a resident’s needs;
      3. c. How a resident’s medical record will be available to individuals providing services to the resident during a disaster;
      4. d. A plan for back-up power and water supply;
      5. e. A plan to ensure a resident’s medications will be available to administer to the resident during a disaster;
      6. f. A plan to ensure a resident is provided nursing services, rehabilitation services, and other services required by the resident during a disaster; and
      7. g. A plan for obtaining food and water for individuals present in the ICF/IID or the ICF/IID’s relocation site during a disaster;
   2. 2. Personnel members receive training on the content and use of the disaster plan required in subsection (A)(1);
   3. 3. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

   4. 4. Documentation of a disaster plan review required in subsection (A)(3) is created, is maintained for at least 12 months after the date of the disaster plan review, and includes:

      1. a. The date and time of the disaster plan review;
      2. b. The name of each personnel member, employee, or volunteer participating in the disaster plan review;
      3. c. A critique of the disaster plan review; and
      4. d. If applicable, recommendations for improvement;
   5. 5. A disaster drill for employees is conducted on each shift at least once every three months and documented;
   6. 6. An evacuation drill for employees is conducted on each shift at least once every three months and documented;

   7. 7. An evacuation drill for residents:

      1. a. Is conducted at least once each year on each shift and documented; and

      2. b. Includes all residents on the premises except for:

         1. i. A resident whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident, and
         2. ii. Sufficient personnel members to ensure the health and safety of residents not evacuated according to subsection (A)(7)(b)(i);

   8. 8. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the drill, and includes:

      1. a. The date and time of the evacuation drill;
      2. b. The amount of time taken for employees and residents to evacuate to a designated area;

      3. c. If applicable:

         1. i. An identification of residents needing assistance for evacuation, and
         2. ii. An identification of residents who were not evacuated;
      4. d. Any problems encountered in conducting the evacuation drill; and
      5. e. Recommendations for improvement, if applicable; and
   9. 9. An evacuation path is conspicuously posted on each hallway of each floor of the ICF/IID.

2. B. An administrator shall ensure that, if an ICF/IID has:

   1. 1. More than 16 residents or a resident who has a medical care plan or whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident:

      1. a. A fire alarm system is installed according to the National Fire Protection Association 72: National Fire Alarm and Signaling Code, incorporated by reference in R9-10-104.01, and is in working order; and
      2. b. A sprinkler system is installed according to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, incorporated by reference in R9-10-104.01, and is in working order; and

   2. 2. Sixteen or fewer residents, none of whom have a medical care plan or whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident:

      1. a. A fire alarm system and a sprinkler system meeting the requirements in subsection (B)(1) are installed and in working order; or

      2. b. The ICF/IID has:

         1. i. A fire extinguisher that is:

            1. (1) Labeled as rated at least 2A-10-BC by the Underwriters Laboratories;
            2. (2) Accessible to personnel members and inaccessible to residents;
            3. (3) If a disposable fire extinguisher, replaced when its indicator reaches the red zone; and
            4. (4) If a rechargeable fire extinguisher, is serviced at least once every 12 months, as documented by a tag attached to the fire extinguisher that specifies the date of the last servicing and the identification of the person who serviced the fire extinguisher; and

         2. ii. Smoke detectors that are:

            1. (1) Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer;
            2. (2) Either battery operated or, if hard-wired into the electrical system of the ICF/IID, has a back-up battery;
            3. (3) In working order; and
            4. (4) Tested at least once a month, with documentation of the test maintained for at least 12 months after the date of the test.

3. C. An administrator shall:

   1. 1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,
   2. 2. Make any repairs or corrections stated on the fire inspection report, and
   3. 3. Maintain documentation of a current fire inspection.
4. D. An administrator shall ensure that, if applicable, a sign is placed at the entrance to a room or area indicating that oxygen is in use.

Historical Note

R9-10-523 made by exempt rulemaking at 25 A.A.R. 1222, effective April 25, 2019 (Supp. 19-2). Amended by exempt rulemaking, at 26 A.A.R. 72 with an effective date of January 1, 2020 (Supp. 19-4).