Florida Regulations 59A-3.078: Comprehensive Emergency Management Plan
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(1) Each hospital shall develop and adopt a written comprehensive emergency management plan for emergency care during an internal or external disaster or an emergency, which is reviewed and updated annually.
(2) The emergency management plan shall be developed in conjunction with other agencies and providers of health care services within the local community pursuant to section 395.1055(1)(c), F.S., and in accordance with the “”Emergency Management Planning Criteria for Hospitals,”” AHCA Form 3130-8005-September 94, which is incorporated by reference. The form is available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #31, Tallahassee, Florida 32308. The plan shall include:
(a) Provisions for internal and external disasters and emergencies;
(b) A description of the hospital’s role in community wide emergency management plans;
(c) Information about how the hospital plans to implement specific procedures outlined in the hospital’s emergency management plan;
(d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions;
(e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in the event of an evacuation order, at the direction of the hospital administrator, or when a determination is made by the Agency that the condition of the facility or its support services is sufficient to render it a hazard to the health and safety of patients and staff, pursuant to chapter 59A-3, F.A.C. Such provisions shall address moving patients within the hospital and relocating patients outside the hospital, including the roles and responsibilities of the physician and the hospital in the decision to move or relocate patients whose life or health is threatened;
(f) Education and training of personnel in carrying out their responsibilities in accordance with the adopted plan;
(g) A provision for coordinating with other hospitals that would receive relocated patients;
(h) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany those patients located at off-site locations;
(i) Provisions for the individual identification of patients, including the transfer of patient records;
(j) Provisions to ensure that a verification check will be made to ensure relocated patients arrive at designated hospitals;
(k) Provisions to ensure that medication needs will be reviewed and advance medication for relocated patients will be forwarded to respective hospitals, when permitted by existing supplies, and state and federal law;
(l) Provisions for essential care and services for patients who may be relocated to the facility during a disaster or an emergency, including staffing, supplies and identification of patients;
(m) Provisions for contacting relatives and necessary persons advising them of patient location changes. A procedure must also be established for responding to inquiries from patient families and the press;
(n) Provisions for the management of supplies, communications, power, emergency equipment, security, and the transfer of records;
(o) Provisions for coordination with designated agencies including the Red Cross and the county emergency management office; and,
(p) Plans for the recovery phase of the operation, to be carried out as soon as possible.
(3) The plan, including the “”Emergency Management Planning Criteria for Hospitals,”” shall be submitted annually to the county emergency management agency for review and approval. A fee may be charged for the review of the plan as authorized by sections 252.35(2)(m) and 252.38(1)(e), F.S.
(a) The county office of emergency management has 60 days in which to review and approve the plan, or advise the facility of necessary revisions. If the county emergency management agency advises the facility of necessary revisions to the plan, those revisions shall be made and the plan resubmitted to the county office of emergency management within 30 days of notification by the county emergency management agency.
(b) The county office of emergency management shall be the final administrative authority for emergency plans developed by hospitals.
(4) The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital’s performance to the hospital’s safety committee. As an alternative, the hospital may test its plan with the frequency specified by an accrediting organization.
(5) The emergency management plan shall be located for immediate access by hospital staff.
(6) In the event a disaster or emergency conditions have been declared by the local emergency management authority, and the hospital does not evacuate the premises, a facility may provide emergency accommodations above the licensed capacity for patients. However, the following conditions must be met:
(a) The facility must report being over capacity and the conditions causing it to the Agency area office within 48 hours or as soon as practical. As an alternative, the facility may report to the Agency central office, Hospital and Outpatient Services Unit, at (850)412-4549;
(b) Life safety cannot be jeopardized for any individual;
(c) The essential needs of patients must be met; and,
(d) The facility must be staffed to meet the essential needs of patients.
(7) If the hospital will be over capacity after the declared disaster or emergency situation ends, the agency shall approve the over capacity situation on a case-by-case basis using the following criteria:
(a) Life safety cannot be jeopardized for any individual;
(b) The essential needs of patients must be met; and,
(c) The facility must be staffed to meet the essential needs of patients.
(8) If a facility evacuates during or after a disaster or an emergency situation, the facility shall not be reoccupied until a determination is made by the hospital administrator that the facility can meet the needs of the patients.
(9) A facility with significant structural damage shall relocate patients until approval is received from the Agency’s Office of Plans and Construction that the facility can be safely reoccupied, in accordance with Fl. Admin. Code R. 59A-3.080
(10) A facility that must evacuate the premises due to a disaster or emergency conditions shall report the evacuation to the Agency area office within 48 hours or as soon as practical. The administrator or designee is responsible for knowing the location of all patients until the patient has been discharged from the facility. The names and location of patients relocated shall be provided to the local emergency management authority or it’s designee having responsibility for tracking the population at large. The licensee shall inform the Agency area office of a contact person who will be available 24 hours a day, seven days a week, until the facility is reoccupied.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055(1)(c) FS. History-New 1-1-77, Formerly 10D-28.78, 10D-28.078, Amended 9-3-92, 12-28-94, 10-16-14.
(a) Provisions for internal and external disasters and emergencies;
(b) A description of the hospital’s role in community wide emergency management plans;
(c) Information about how the hospital plans to implement specific procedures outlined in the hospital’s emergency management plan;
(d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions;
(e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in the event of an evacuation order, at the direction of the hospital administrator, or when a determination is made by the Agency that the condition of the facility or its support services is sufficient to render it a hazard to the health and safety of patients and staff, pursuant to chapter 59A-3, F.A.C. Such provisions shall address moving patients within the hospital and relocating patients outside the hospital, including the roles and responsibilities of the physician and the hospital in the decision to move or relocate patients whose life or health is threatened;
(f) Education and training of personnel in carrying out their responsibilities in accordance with the adopted plan;
(g) A provision for coordinating with other hospitals that would receive relocated patients;
(h) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany those patients located at off-site locations;
(i) Provisions for the individual identification of patients, including the transfer of patient records;
(j) Provisions to ensure that a verification check will be made to ensure relocated patients arrive at designated hospitals;
(k) Provisions to ensure that medication needs will be reviewed and advance medication for relocated patients will be forwarded to respective hospitals, when permitted by existing supplies, and state and federal law;
(l) Provisions for essential care and services for patients who may be relocated to the facility during a disaster or an emergency, including staffing, supplies and identification of patients;
(m) Provisions for contacting relatives and necessary persons advising them of patient location changes. A procedure must also be established for responding to inquiries from patient families and the press;
(n) Provisions for the management of supplies, communications, power, emergency equipment, security, and the transfer of records;
(o) Provisions for coordination with designated agencies including the Red Cross and the county emergency management office; and,
(p) Plans for the recovery phase of the operation, to be carried out as soon as possible.
(3) The plan, including the “”Emergency Management Planning Criteria for Hospitals,”” shall be submitted annually to the county emergency management agency for review and approval. A fee may be charged for the review of the plan as authorized by sections 252.35(2)(m) and 252.38(1)(e), F.S.
(a) The county office of emergency management has 60 days in which to review and approve the plan, or advise the facility of necessary revisions. If the county emergency management agency advises the facility of necessary revisions to the plan, those revisions shall be made and the plan resubmitted to the county office of emergency management within 30 days of notification by the county emergency management agency.
(b) The county office of emergency management shall be the final administrative authority for emergency plans developed by hospitals.
(4) The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital’s performance to the hospital’s safety committee. As an alternative, the hospital may test its plan with the frequency specified by an accrediting organization.
(5) The emergency management plan shall be located for immediate access by hospital staff.
(6) In the event a disaster or emergency conditions have been declared by the local emergency management authority, and the hospital does not evacuate the premises, a facility may provide emergency accommodations above the licensed capacity for patients. However, the following conditions must be met:
(a) The facility must report being over capacity and the conditions causing it to the Agency area office within 48 hours or as soon as practical. As an alternative, the facility may report to the Agency central office, Hospital and Outpatient Services Unit, at (850)412-4549;
(b) Life safety cannot be jeopardized for any individual;
(c) The essential needs of patients must be met; and,
(d) The facility must be staffed to meet the essential needs of patients.
(7) If the hospital will be over capacity after the declared disaster or emergency situation ends, the agency shall approve the over capacity situation on a case-by-case basis using the following criteria:
(a) Life safety cannot be jeopardized for any individual;
(b) The essential needs of patients must be met; and,
(c) The facility must be staffed to meet the essential needs of patients.
(8) If a facility evacuates during or after a disaster or an emergency situation, the facility shall not be reoccupied until a determination is made by the hospital administrator that the facility can meet the needs of the patients.
(9) A facility with significant structural damage shall relocate patients until approval is received from the Agency’s Office of Plans and Construction that the facility can be safely reoccupied, in accordance with Fl. Admin. Code R. 59A-3.080
(10) A facility that must evacuate the premises due to a disaster or emergency conditions shall report the evacuation to the Agency area office within 48 hours or as soon as practical. The administrator or designee is responsible for knowing the location of all patients until the patient has been discharged from the facility. The names and location of patients relocated shall be provided to the local emergency management authority or it’s designee having responsibility for tracking the population at large. The licensee shall inform the Agency area office of a contact person who will be available 24 hours a day, seven days a week, until the facility is reoccupied.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055(1)(c) FS. History-New 1-1-77, Formerly 10D-28.78, 10D-28.078, Amended 9-3-92, 12-28-94, 10-16-14.