1. (a) Each facility shall have an individual or group, known as an emergency management committee, of which the facility administrator shall be a member.
2. (b) The emergency management committee shall have the authority for developing, implementing, exercising, and evaluating an emergency preparedness plan .

3. (c) The emergency management committee shall include other individuals who have knowledge of the facility and the capability to identify resources from key functional areas within the facility and shall solicit applicable external representation including but not limited to:

   1. (1) Elected state and local officials;
   2. (2) Police, fire, civil defense, and public health professionals;
   3. (3) Environment, transportation, and hospital officials;
   4. (4) Facility representatives; and
   5. (5) Representatives from community groups and the media.

4. (d) An emergency management program shall include, at a minimum, the following elements:

   1. (1) The emergency preparedness plan, as described in (e) and (f) below;
   2. (2) The roles and responsibilities of the committee members;
   3. (3) A description of how the plan is implemented, exercised, and maintained; and
   4. (4) Accommodation for emergency food and water supplies.
5. (e) The emergency management committee shall develop and institute a written emergency preparedness plan to respond to a disaster or an emergency.

6. (f) The emergency preparedness plan in (e) above shall:

   1. (1) Include site-specific plans for the protection of all persons on-site in the event of fire, natural disaster, severe weather, or human-caused emergency such as missing patients and bomb threat;
   2. (2) Be approved by the local emergency management director and reviewed and approved, as appropriate, by the local fire department;
   3. (3) Be available to all personnel;
   4. (4) Be based on realistic conceptual events;
   5. (5) Be modeled on the Incident Command System (ICS) in coordination with local emergency response agencies;
   6. (6) Provide that all personnel designated or involved in the emergency preparedness plan of the facility shall be supplied with a means of identification, such as vests, baseball caps, or hard hats, which shall be worn at all times in a visible location during the emergency;
   7. (7) Develop and implement a strategy to prevent an incident that threatens life, property, and the environment of the facility;
   8. (8) Develop and implement a mitigation strategy that includes measures to be taken to limit or control the consequences, extent, or severity of an incident that cannot be prevented;
   9. (9) Develop and implement a protection strategy to protect life, property, and the environment from human caused incidents and events and from natural disasters;
   10. (10) For (7)-(9) above, incorporate the findings of a hazard vulnerability assessment, the results of an analysis of impact, program constraints, operational experience, and cost-benefit analysis to provide strategies that can realistically be implemented without requiring undue expenses to the -licensee;
   11. (11) Conduct a facility-wide walk-through and review, to include the property that the licensee is located on, to determine the status of hazards that might be incorporated into the prevention, protection, and mitigation strategies and to determine the outcome of prior strategies at least annually;

   12. (12) Include the licensee’s response to both short-term and long-term interruptions in the availability of utility service in the disaster or emergency, including establishing contingency plans for continuity of essential building systems or evacuation to include the following, as applicable:

       1. a. Electricity;
       2. b. Potable water;
       3. c. Non-potable water;
       4. d. Heating, ventilation, and air conditioning (HVAC);
       5. e. Fire protection systems;
       6. f. Fuel required for building operations to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;
       7. g. Fuel for essential transportation to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;
       8. h. Medical gas and vacuum systems, if applicable;
       9. i. Communications systems; and
       10. j. Essential services, such as kitchen and laundry services, if applicable;
   13. (13) Include a plan for alerting and managing staff in a disaster, and accessing Critical Incident Stress Management (CISM), if necessary;

   14. (14) Include the management of patients, particularly with respect to physical and clinical issues to include:

       1. a. Relocation of patients with their medical record including the medicine administration records, if time permits, as detailed in the emergency plan;
       2. b. Access, as appropriate, to critical materials such as pharmaceuticals, medical supplies, food supplies, linen supplies, and industrial and potable water; and
       3. c. How to provide security during the disaster;
   15. (15) Identify a designated media spokesperson to issue news releases and an area where the media can be assembled and in a location where they will not interfere with the operations of the facility;
   16. (16) Reflect measures needed to restore operational capability with consideration of fiscal aspects because of restoration costs and possible cash flow losses associated with the disruption;
   17. (17) Include an educational, competency-based program for the staff, to provide an overview of the components of the emergency management program and concepts of the ICS and the staff’s specific duties and responsibilities; and
   18. (18) If the -licensee is located within 10 miles of a nuclear power plant and is part of the New Hampshire Radiological Emergency Response Plan (RERP), include the required elements of the RERP.

7. (g) The licensee shall conduct and document with a detailed log, including personnel signatures, 2 drills a year. A drill might include testing the facility’s communication systems and contact lists to include local authorities, the state authorities, and any other call trees the facility might utilize. One drill might be to rehearse mass casualty, if available, to the facility’s response with emergency services, disaster receiving stations, or both. If a mass casualty drill is utilized it shall comply with the following:

   1. (1) Drills and exercises shall be monitored by at least one designated evaluator who has knowledge of the -licensee’s plan and who is not involved in the exercise;
   2. (2) Drills and exercises shall evaluate program plans, procedures, training, and capabilities to identify opportunities for improvement;
   3. (3) The –licensee shall conduct a debriefing session not more than 72 hours after the conclusion of the drill or exercise. The debriefing shall include all key individuals, including observers, administration, clinical staff, and appropriate support staff; and
   4. (4) Exercises and actual events shall be critiqued to identify areas for improvement. The critique shall identify areas of non-compliance and opportunities for improvement based upon monitoring activities and observations during the exercise. Opportunities for improvement identified in critiques shall be incorporated in the -licensee’s improvement plan.
8. (h) For the purposes of emergency preparedness, each licensee shall have in writing, a plan for the management of emergency treatment supplies such as potable water for treatment, water treatment equipment, dialyzers, blood lines, saline, medications, and any other necessary equipment.

Source. #14206, eff 2-28-25 (formerly He-P 811.27)