1. (1) The licensee shall have an emergency operations plan for the maintenance of a safe environment in the event of an emergency or disaster that overwhelms the facility.

2. (2) The administrator or designee is responsible for the development of the plan, coordinated with applicable state and local emergency response partners and agencies. The plan shall:

   1. (a) address delivery of essential care and services to hospital occupants utilizing crisis standards of care when staff is reduced by an emergency;
   2. (b) address delivery of essential care and services when additional persons are present at the hospital during an emergency;

   3. (c) address planning, mitigation, response, and recovery for:

      1. (i) emergency communications;
      2. (ii) patient clinical and supportive activities;
      3. (iii) safety and security;
      4. (iv) staff responsibilities;
      5. (v) resources and assets; and
      6. (vi) utility management;
   4. (d) address risks and threats identified in the licensee's annual hazard vulnerability analysis;
   5. (e) be in writing and made available to any hospital staff;
   6. (f) be reviewed and updated as necessary and be available for review by the department;
   7. (g) delineate individuals who will be in charge in the event of any significant emergency;

   8. (h) delineate the person with decision-making authority to activate the emergency operations plan;

      1. (i) have an evacuation plan; and
   9. (j) include readily available lists of emergency partners with multiple contact options, emergency contact lists are updated and maintained regularly by the licensee.
3. (3) The hospital administrator and the board shall approve the emergency operations plan.
4. (4) The licensee shall document any emergency incidents and responses.
5. (5) The licensee shall hold disaster drills or exercises twice yearly according to threats identified in the facility's annual hazard vulnerability analysis.
6. (6) The licensee shall have a fire emergency evacuation plan written in consultation with qualified fire safety personnel. This plan may be included in the facility's emergency operations plan.
7. (7) The licensee shall post evacuation routes posted in prominent locations throughout the hospital.
8. (8) The licensee shall document fire drills and ensure fire drill documentation is in accordance with Rule R710-4.

9. (9)(a) A licensee may exceed the licensed capacity by up to 20% in response to any incident that overwhelms the facility.

   1. (b) A hospital that exceeds the licensed capacity under this provision shall notify the department within 72 hours of exceeding the licensed capacity.
   2. (c) The licensee shall seek department approval to exceed 20% above licensed capacity.
   3. (d) The department may direct that the licensee reduce the patient census to the licensed capacity at any time.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203