A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. (Critical Access Hospitals are certified under separate standards. Psychiatric Hospitals are subject to additional regulations beyond basic hospital conditions of participation.) Inpatient Rehabilitation Facilities and Long Term Care Hospitals are included in the Hospital definition.
Hospitals are also required to conduct planning and preparedness activities that are applicable to an affiliated accrediting organization as well as the New Hampshire Administrative Rules for Hospitals under He-P 802.
Your hospital should develop a plan based on the risk assessment and planning done earlier in the toolkit. The plan should:
The policies and procedures included in an emergency preparedness plan need to, at minimum, address the following:
The hospital needs to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. This plan should be reviewed and updated at least annually, and must include the following:
Hospitals must develop and maintain an emergency preparedness training and testing program based on the risk assessment, policies and procedures, and communications planning above. It must be reviewed and updated at least annually.
Training Program
A training program includes all of the following:
Testing
The hospital must conduct exercises to test the emergency plan at least annually, by doing all of the following:
Documentation that analyzes the hospitals response and documentation of all drills, exercises and emergency events and revisions to the plan as needed is required.
Emergency Standby and Power Systems
The hospital must implement emergency and standby power systems based on the plans set forth in the above sections. It should include:
Integrated Health Systems
If the hospital is part of a healthcare system, consisting of multiple separately certified facilities that elects to have a unified and integrated emergency preparedness program, it can participate in the system's coordinated emergency preparedness program.
If participating in the program, the unified and integrated emergency preparedness program must: