59A-5.018. Comprehensive Emergency Management Plan

(1) Each center shall develop and adopt a written comprehensive emergency management plan for emergency care during an internal or external disaster or emergency which it shall review and update 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 252.32(2), F.S., and in accordance with the “Emergency Management Planning Criteria for Ambulatory Surgical Centers”, AHCA FORM 3130-2003 July 94, which is incorporated by reference. The form is available at: http://www.flrules.org/Gateway/reference.asp?No=Ref-04454 and available from the Agency for Health Care Administration at:

http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/forms/ASC_CEMP_Reconstructed_122104.pdf

The plan shall include:

(a) Provisions for internal and external disasters, and emergencies;

(b) A description of the center’s role in a community wide comprehensive emergency management plan;

(c) Information about how the center plans to implement specific procedures outlined in its comprehensive emergency management plan;

(d) Precautionary measures, including voluntary cessation of center operations, to be taken by the center in preparation and response to warnings of inclement weather, including hurricanes and tornadoes, or other potential emergency conditions.

(e) Provisions for the management of patients, including the discharge or transfer of patients and staff to a hospital or subacute care facility, at the direction of the center’s administrator, in the event of an evacuation order, or when a determination is made by the Agency that the condition of the center is sufficient to render it a hazard to the health and safety of patients and staff, pursuant to Chapter 59A-5, F.A.C. Such provisions shall address the role and responsibility of the physician in the decision to move or relocate patients;

(f) Provisions for coordinating with hospitals that would receive patients to be transferred;

(g) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany patients to a hospital or subacute care facility;

(h) A provision that a verification check will be made to ensure patients transferred to a hospital arrive at the designated hospital;

(i) A provision that ensures that copies of medical records and orders accompany patients transferred to a hospital;

(j) Provisions for the management of patients who may be treated at the center during an internal or external disaster or emergencies, including control of patient information and medical records, individual identification of patients, transfer of patients to hospital(s) and treatment of mass casualties;

(k) 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;

(l) A provision for educating and training personnel in carrying out their responsibilities in accordance with the adopted plan;

(m) Identification of mutual aid agreements or statements of understanding for services; and

(n) Provisions for coordination with designated agencies.

(3) The plan, including appendices, as required by the “Emergency Management Planning Criteria for Ambulatory Surgical Centers”, 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 emergency management agency has 60 days upon receipt of the plan, in which to review and approve the plan, or advise the center of necessary revisions. If the county emergency management agency advises the center of necessary revisions to the plan, those revisions shall be made as authorized by Section 395.1055(1)(c), F.S., and the plan shall be resubmitted to the county emergency management agency within 30 days of notification by the county emergency management agency.

(b) The county emergency management agency shall be the final administrative authority for emergency management plans developed by centers.

(4) The center shall test the implementation of the emergency management plan semiannually, either in response to an emergency or in a planned drill, and shall evaluate and document the center’s performance. This documentation must be on file at the center and available for inspection by the county emergency management agency and the Agency.

(5) The emergency management plan shall be available for immediate access by the staff.

(6) If a center evacuates during or after an emergency, the center shall not be reoccupied until a determination is made by the center’s administrator that the center can meet the needs of the patients. A center with significant structural damage shall not be reoccupied until approval is received from the Agency’s Office of Plans and Construction that the center can be safely occupied as required by the Florida Building Code.

(7) A center that must evacuate the premises due to a disaster or an emergency condition, shall report the evacuation to the Agency’s local area health facility regulation office within 24 hours or as soon as practical. The names and destination of patients relocated shall be provided to the county emergency management agency or its designee having responsibility for tracking the population at large. The licensee shall inform the Agency’s local area office of a contact person who will be available 24 hours a day, seven days a week, until the center is reoccupied.

Rulemaking Authority 395.1055 FS. Law Implemented 395.1055 FS. History–New 6-14-78, Formerly 10D-30.18, 10D-30.018, Amended 12-28-94, 9-17-14.