Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 558 - LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES › Subchapter H - STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES › Division 7 - HOSPICE INPATIENT UNITS › Section 558.871 - Physical Environment in a Hospice Inpatient Unit

Current through Reg. 49, No. 28; July 12, 2024
(a) Safety Management. A hospice inpatient
					 unit must maintain a safe physical environment free of hazards for clients,
					 staff, and visitors.
(1) A hospice inpatient
					 unit must address real or potential threats to the health and safety of the
					 clients, others, and property.
(2)
					 In addition to § 558.256 of this chapter (relating to Emergency
					 Preparedness Planning and Implementation), a hospice inpatient unit must have a
					 written disaster preparedness plan that addresses the core functions of
					 emergency management as described in subparagraphs (A) - (G) of this paragraph.
					 The facility must maintain documentation of compliance with this paragraph.
(A) The portion of the plan on direction and
					 control must:
(i) designate a person by
					 position, and at least one alternate, to be in charge during implementation of
					 an emergency response plan, with authority to execute a plan to evacuate or
					 shelter in place;
(ii) include
					 procedures the facility will use to maintain continuous leadership and
					 authority in key positions;
(iii)
					 include procedures the facility will use to activate a timely response plan
					 based on the types of disasters identified in the risk assessment;
(iv) include procedures the facility will use
					 to meet staffing requirements;
(v)
					 include procedures the facility will use to warn or notify facility staff about
					 internal and external disasters, including during off hours, weekends, and
					 holidays;
(vi) include procedures
					 the facility will use to maintain a current list of who the hospice will notify
					 once warning of a disaster is received;
(vii) include procedures the facility will
					 use to alert critical facility personnel once a disaster is identified;
					 and
(viii) include procedures the
					 facility will use to maintain a current 24-hour contact list for all
					 personnel.
(B) The
					 portion of the plan on communication must include procedures:
(i) for continued communication, including
					 procedures during an evacuation to maintain contact with critical personnel and
					 with all vehicles traveling in an evacuation caravan;
(ii) to maintain an accessible, current list
					 of the phone numbers of:
(I) client family
					 members;
(II) local
					 shelters;
(III) prearranged
					 receiving facilities;
(IV) the
					 local emergency management agencies;
(V) other health care providers;
					 and
(VI) State and federal
					 emergency management agencies;
(iii) to notify staff, clients, families of
					 clients, families of critical staff, prearranged receiving facilities, and
					 others of an evacuation or the plan to shelter in place;
(iv) to provide a contact number for
					 out-of-town family members to call for information; and
(v) to relocate and track clients during
					 disasters that require mass evacuations.
(C) The portion of the plan on resource
					 management must include procedures:
(i) to
					 maintain contracts and agreements with vendors as needed to ensure the
					 availability of the supplies and transportation needed to execute the plan to
					 shelter in place or evacuate;
(ii)
					 to develop accurate, detailed, and current checklists of essential supplies,
					 staff, equipment, and medications;
(iii) to designate responsibility for
					 completing the checklists during disaster operations;
(iv) for the safe and secure transportation
					 of adequate amounts of food, water, medications, and critical supplies and
					 equipment during an evacuation; and
(v) to maintain a supply of sufficient
					 resources for at least seven days to shelter in place, which must include:
(I) emergency power, including backup
					 generators and accounts for maintaining a supply of fuel;
(II) potable water in an amount based on
					 population and location;
(III) the
					 types and amounts of food for the number and types of clients served;
(IV) extra pharmacy stocks of common
					 medications; and
(V) extra medical
					 supplies and equipment, such as oxygen, linens, and any other vital
					 equipment.
(D) The portion of the plan on sheltering in
					 place must:
(i) be developed using information
					 about the building's construction and Life Safety Code (LSC) systems;
(ii) describe the criteria to be used to
					 decide whether to shelter in place versus evacuate;
(iii) include procedures to assess whether
					 the building is strong enough to withstand the various types of possible
					 disasters and to identify the safest areas of the building;
(iv) include procedures to secure the
					 building against damage;
(v)
					 include procedures for collaborating with the local emergency management
					 agencies regarding the decision to shelter in place;
(vi) include procedures to assign each task
					 in the sheltering plan to facility staff;
(vii) describe procedures to shelter in place
					 that allow the facility to maintain 24-hour operations for a minimum of seven
					 days to maintain continuity of care for the number and types of clients served;
					 and
(viii) include procedures to
					 provide for building security.
(E) The portion of the plan on evacuation
					 must:
(i) include contracts with prearranged
					 receiving facilities, including a hospice inpatient facility, skilled nursing
					 facility, nursing facility, assisted living facility, or hospital, with at
					 least one facility located at least 50 miles away;
(ii) include procedures to identify and
					 follow evacuation and alternative routes for transporting clients to a
					 receiving facility and to notify the proper authorities of the decision to
					 evacuate;
(iii) include procedures
					 to protect and transport client records and to match them to each
					 client;
(iv) include procedures to
					 maintain a checklist of items to be transported with clients, including
					 medications and assistive devices, and how the items will be matched to each
					 client;
(v) include staffing
					 procedures the facility will use to ensure that staff accompanies evacuating
					 clients when the hospice transports clients to a receiving facility;
(vi) include procedures to identify and
					 assign staff responsibilities, including how clients will be cared for during
					 evacuations and a backup plan for lack of sufficient staff;
(vii) include procedures facility staff will
					 use to account for all persons in the building during the evacuation and to
					 track all persons evacuated;
(viii)
					 include procedures for the use, protection, and security of the identifying
					 information the facility will use to identify evacuated clients;
(ix) include procedures facility staff will
					 follow if a client becomes ill or dies in route when the hospice transports
					 clients to a receiving facility;
(x) include procedures to make a hospice
					 counselor available when staff accompanies clients during transport by the
					 hospice to a receiving facility;
(xi) include the facility's policy on whether
					 family of staff and clients can shelter at the hospice and evacuate with staff
					 and clients;
(xii) include
					 procedures to coordinate building security with the local emergency management
					 agencies;
(xiii) include procedures
					 facility staff will use to determine when it is safe to return to the
					 geographical area;
(xiv) include
					 procedures facility staff will use to determine if the building is safe for
					 reoccupation; and
(xv) be approved
					 by the local emergency management coordinator (EMC) at least annually and when
					 updated.
(F) The portion
					 of the plan on transportation must:
(i)
					 describe how the hospice prearranges for a sufficient number of vehicles to
					 provide suitable, safe transportation for the type and number of clients being
					 served; and
(ii) include procedures
					 to contact the local EMC to coordinate the facility's transportation needs in
					 the event its prearrangements for transportation fail for reasons beyond the
					 facility's control.
(G)
					 The portion of the plan on training must include:
(i) procedures that specify when and how the
					 disaster response plan is reviewed with clients and family members;
(ii) procedures to review the role and
					 responsibility of a client able to participate with the plan;
(iii) procedures for initial and periodic
					 training for all facility staff to carry out the plan;
(iv) the frequency for conducting disaster
					 drills and demonstrations to ensure staff are fully trained with respect to
					 their duties under the plan; and
(v) procedures to conduct emergency response
					 drills at least annually either in response to an actual disaster or in a
					 planned drill, which may be in addition to or combined with the drills required
					 by the LSC as specified in subsection (c)(1) of this section.