Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part I - General Administration › Subpart 3 - Licensing and Certification › Chapter 45 - Ambulatory Surgical Center › Subchapter F - Safety, Sanitization and Emergency Preparedness › Section I-4581 - Emergency Preparedness and Emergency Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. Disaster and emergency plans shall be
					 developed by the governing body, and updated annually, which are based on a
					 risk assessment using an all hazards approach for both internal and external
					 occurrences. Disaster and emergency plans shall include provisions for persons
					 with disabilities.
B. The ASC shall
					 develop and implement policies and procedures based on the emergency plan, risk
					 assessment and communication plan which shall be reviewed and updated at least
					 annually. Such policies shall include a system to track on duty staff and
					 sheltered patients, if any, during the emergency.
C. The ASC shall develop and maintain an
					 emergency preparedness communication plan that complies with both federal and
					 state laws. Patient care shall be well-coordinated within the ASC, across
					 health care providers and with state and local public health departments and
					 emergency systems.
D. The ASC shall
					 develop and maintain training and testing programs, including initial training
					 in policies and procedures and demonstrate knowledge of emergency procedures.
					 Such training shall be provided at least annually.
E. Additional Requirements
1. Each ASC shall post exit signs and
					 diagrams conspicuously through the facility.
2. Flash lights or battery operated lamps for
					 emergency use shall be available for ASC personnel and kept in operational
					 condition.
3. The ASC shall ensure
					 that emergency equipment is:
a. immediately
					 available for use during emergency situations;
b. appropriate for the ASC's patient
					 population; and
c. maintained by
					 appropriate personnel.
4. The ASC shall have written policies and
					 procedures that address the availability and relevant use of the following
					 emergency equipment in the ASC's operating/procedure rooms sufficient in number
					 to handle multiple simultaneous emergencies:
a. emergency call system;
b. oxygen;
c. mechanical ventilatory assistance
					 equipment, including:
i. airways;
ii. manual breathing bag; and
iii. ventilator;
d. cardiac defibrillator;
e. cardiac monitoring equipment;
f. tracheostomy set;
g. laryngoscope and endotracheal
					 tubes;
h. suction equipment;
					 and
i. any other emergency medical
					 equipment and supplies specified by the medical staff and approved by the
					 governing body for treatment of all age groups serviced in the ASC.
5. The ASC shall have an operable
					 backup generator of sufficient size to support and maintain necessary
					 life-sustaining medical equipment.
a. A
					 sufficient amount of fuel shall be maintained to ensure the operation of the
					 generator for at least four hours to maintain:
i. temperatures to protect patient health and
					 safety and for the safe and sanitary storage of provisions;
ii. emergency lighting; and
iii. fire detection, extinguishing and alarm
					 systems.
6.
					 The ASC is responsible for:
a. developing and
					 implementing policies and procedures for the safe emergency transfer of
					 patients from the ASC in the event that an emergency impacts the ASCs ability
					 to provide services;
b. developing
					 policies that address what types of emergency procedures, equipment and
					 medications shall be available; and
c. providing trained staff to sustain the
					 life of the patient prior to the transfer.