Section R9-10-1029. Emergency and Safety Standards

A.      An administrator shall ensure that policies and procedures for providing emergency treatment are established, documented, and implemented that protect the health and safety of patients and include:

1.        A list of the medications, supplies, and equipment required on the premises for the emergency treatment provided by the outpatient treatment center;

2.        A system to ensure medications, supplies, and equipment are available, have not been tampered with, and, if appli- cable, have not expired;

3.        A requirement that a cart or a container is available for emergency treatment that contains the medication, sup- plies, and equipment specified in the outpatient treatment center’s policies and procedures; and

4.        A method to verify and document that the contents of the cart or container are available for emergency treatment.

B.       An administrator shall ensure that emergency treatment is pro- vided to a patient admitted to the outpatient treatment center according to the outpatient treatment center’s policies and pro- cedures.

C.      An administrator shall ensure that:

1.        A disaster plan is developed, documented, maintained in a location accessible to personnel members, and, if neces- sary, implemented that includes:

a.         Procedures for protecting the health and safety of patients and other individuals on the premises;

b.        Assigned responsibilities for each personnel mem- ber, employee, or volunteer;

c.         Instructions for the evacuation of patients and other individuals on the premises; and

d.        Arrangements to provide medical services, nursing services, and health-related services to meet patients' needs;

2.        The disaster plan required in subsection (C)(1) is reviewed at least once every 12 months;

3.        An evacuation drill is conducted on each shift at least once every 12 months;

4.        A disaster plan review required in subsection (C)(2) or an evacuation drill required in subsection (C)(3) is docu- mented as follows:

a.         The date and time of the evacuation drill or disaster plan review;

b.        The name of each personnel member, employee, or volunteer participating in the evacuation drill or disaster plan review;

c.         A critique of the evacuation drill or disaster plan review; and

d.        If applicable, recommendations for improvement;

5.        Documentation required in subsection (C)(4) is main- tained for at least 12 months after the date of the evacua- tion drill or disaster plan review; and

6.        An evacuation path is conspicuously posted on each hall- way of each floor of the outpatient treatment center.

D.      An administrator shall ensure that an outpatient treatment cen- ter has either:

1.        Both of the following that are tested and serviced at least once every 12 months:

a.         A fire alarm system installed according to the National Fire Protection Association 72: National

Fire Alarm and Signaling Code, incorporated by ref- erence in A.A.C. R9-1-412, that is in working order; and

b.        A sprinkler  system  installed according  to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, incorporated by reference in A.A.C. R9-1-412, that is in working order; or

2.        The following:

a.         A smoke detector installed in each hallway of the outpatient treatment center that is:

i.         Maintained in an operable condition;

ii.        Either battery operated or, if hard-wired into the electrical system of the outpatient treatment center, has a back-up battery; and

iii.      Tested monthly; and

b.        A portable, operable fire extinguisher, labeled as rated at least 2A-10-BC by the Underwriters Labora- tories, that:

i.         Is available at the outpatient treatment center;

ii.        Is mounted in a fire extinguisher cabinet or placed on wall brackets so that the top handle of the fire extinguisher is not over five feet from the floor and the bottom of the fire extin- guisher is at least four inches from the floor;

iii.      If a disposable fire extinguisher, is  replaced when its indicator reaches the red zone; and

iv.       If a rechargeable fire extinguisher, is serviced at least once every 12 months and has a tag attached to the fire extinguisher that specifies the date of the last servicing and the name of the servicing person.

E.       An administrator shall ensure that documentation of a test required in subsection (D) is maintained for at least 12 months after the date of the test.

F.       An administrator shall ensure that:

1.        Exit signs are illuminated, if the local fire jurisdiction requires illuminated exit signs;

2.        Except as provided in subsection (G), a corridor in the outpatient treatment center is at least 44 inches wide;

3.        Corridors and exits are kept clear of any obstructions;

4.        A patient can exit through any exit during hours of opera- tion;

5.        An extension cord is not used instead of permanent elec- trical wiring;

6.        Each electrical outlet and electrical switch has a cover plate that is in good repair;

7.        If applicable, a sign is placed at the entrance of a room or an area indicating that oxygen is in use; and

8.        Oxygen and medical gas containers:

a.         Are maintained in a secured, upright position; and

b.        Are stored in a room with a door:

i.         In a building with sprinklers, at least five feet from any combustible materials; or

ii.        In a building without sprinklers, at least 20 feet from any combustible materials.

G.      If an outpatient treatment center licensed before October 1, 2013 has a corridor less than 44 inches wide, an administrator shall ensure that:

1.        The corridor is wide enough to allow for:

a.         Unobstructed movement of patients within the out- patient treatment center, and

b.        The safe evacuation of patients from the outpatient treatment center; and

2.        The corridor is used only as a passageway.

H.      An administrator shall:

1.        Obtain a fire inspection conducted according to the time- frame established by the local fire department or the State Fire Marshal,

2.        Make any repairs or corrections stated on the fire inspec- tion report, and

3.        Maintain documentation of a current fire inspection.

Historical Note

Adopted as an emergency effective November 17, 1983, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 83-6). Former Section R9-10-1029 adopted as an emergency now adopted and amended as a permanent rule effective February 15, 1984 (Supp. 84-1). Repealed by summary action, interim effective date July 21, 1995 (Supp. 95-3). The proposed summary action repealing R9-10-1029 was remanded by the Governor’s Regulatory Review Council which revoked the interim effectiveness of the summary rule. The Section in effect before the pro- posed summary action has been restored (Supp. 97-1).

Section repealed by final rulemaking at 5 A.A.R. 1222, effective April 5, 1999 (Supp. 99-2). New Section made by exempt rulemaking at 19 A.A.R. 2015, effective Octo- ber 1, 2013 (Supp. 13-2). Amended by exempt rulemak-

ing at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, §

13; effective July 1, 2014 (Supp. 14-2).