Section R9-10-1315. Emergency and Safety Standards

A.      A medical director shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include:

1.        The medications, supplies, and equipment required on the premises for the medical emergency treatment provided by the behavioral health specialized transitional facility;

2.        A system to ensure all medications, supplies, and equip- ment are available, have not been tampered with, and, if applicable, have not expired;

3.        A requirement that a cart or container is available for medical emergency treatment that contains all of the medication, supplies, and equipment specified in the behavioral health specialized transitional facility’s poli- cies and procedures;

4.        A method to verify and document that the contents of the cart or container in subsection (A)(3) are available for medical emergency treatment; and

5.        A method for ensuring a patient may be transported to a hospital or other health care institution to receive treat- ment for a medical emergency that the behavioral health specialized transitional facility is not able or not autho- rized to provide.

B.       An administrator shall ensure that medical emergency treat- ment is provided to a patient admitted to the behavioral health specialized transitional facility according to the behavioral health specialized transitional facility’s policies and proce- dures.

C.      An administrator shall ensure that the behavioral health spe- cialized transitional facility has:

1.        A fire alarm system installed according to the National Fire Protection Association 72: National Fire Alarm and Signaling Code, incorporated by reference in A.A.C. R9- 1-412, that is in working order; and a sprinkler system installed according to the National Fire Protection Asso- ciation 13 Standard for the Installation of Sprinkler Sys- tems, incorporated by reference in A.A.C. R9-1-412, that is in working order; or

2.        An alternative method to ensure a patient’s safety, docu- mented and approved by the local jurisdiction.

D.      An administrator shall ensure that:

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

a.         Procedures for protecting the health and safety of patients and other individuals at the behavioral health specialized transitional facility;

b.        When, how, and where patients will be relocated;

c.         How each patient’s medical record will be available to personnel providing services to the patient during a disaster;

d.        A plan to ensure each patient’s medication will be available to administer to the patient during a disas- ter; and

e.         A plan for obtaining food and water for individuals present in the behavioral health specialized transi- tional facility or the behavioral health specialized transitional facility's relocation site during a disaster;

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

3.        A disaster drill is performed on each shift at least once every 12 months;

4.        Documentation of a disaster plan review required in sub- section (D)(2) and a disaster drill required in subsection (D)(3) is created, is maintained for at least 12 months after the date of the disaster plan review or disaster drill, and includes:

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

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

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

d.        If applicable, recommendations for improvement;

5.        An evacuation drill is conducted on each shift at least once every three months;

6.        Documentation of an evacuation drill is created, is main- tained for at least 12 months after the date of the evacua- tion drill, and includes:

a.         The date and time of the evacuation drill;

b.        The amount of time taken for all employees and patients to evacuate the behavioral health special- ized transitional facility;

c.         If applicable, an identification of patients needing assistance for evacuation;

d.        Any problems encountered in conducting the evacu- ation drill; and

e.         Recommendations for improvement, if applicable; and

7.        An evacuation path is conspicuously posted on each hall- way of each floor of the behavioral health specialized transitional facility.

E.       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

Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).