Ariz. Admin. Code § R9-10-322 - Emergency and Safety Standards

A. An administrator shall ensure that a behavioral health inpatient facility has:

1. A fire alarm system installed according to the National Fire Protection Association 72: National Fire Alarm and Signaling Code, incorporated by reference in R9-10-104.01, and a sprinkler system installed according to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, incorporated by reference in R9-10-104.01, that are in working order; or

2. An alternative method to ensure a patient's safety, documented and approved by the local jurisdiction.

B. An administrator shall ensure that:

1. A disaster plan is developed, documented, maintained in a location accessible to personnel members and other employees, and, if necessary, implemented that includes:

a. When, how, and where patients will be relocated;

b. How a patient's medical record will be available to individuals providing services to the patient during a disaster;

c. A plan to ensure each patient's medication will be available to administer to the patient during a disaster; and

d. A plan for obtaining food and water for individuals present in the behavioral health inpatient facility or the behavioral health inpatient facility's relocation site during a disaster;

2. The disaster plan required in subsection (B)(1) is reviewed at least once every 12 months;

3. Documentation of a disaster plan review required in subsection (B)(2) is created, is maintained for at least 12 months after the date of the disaster plan review, and includes:

a. The date and time of the disaster plan review;

b. The name of each personnel member, employee, volunteer, or student participating in the disaster plan review;

c. A critique of the disaster plan review; and

d. If applicable, recommendations for improvement;

4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

5. An evacuation drill for employees and patients:

a. Is conducted at least once every six months; and

b. Includes all individuals on the premises except for:

i. A patient whose medical record contains documentation that evacuation from the behavioral health inpatient facility would cause harm to the patient, and

ii. Sufficient personnel members to ensure the health and safety of patients not evacuated according to subsection (B)(5)(b)(i);

6. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes:

a. The date and time of the evacuation drill;

b. The amount of time taken for employees and patients to evacuate to a designated area;

c. If applicable:

i. An identification of patients needing assistance for evacuation, and

ii. An identification of patients who were not evacuated;

d. Any problems encountered in conducting the evacuation drill; and

e. Recommendations for improvement, if applicable; and

7. An evacuation path is conspicuously posted on each hallway of each floor of the behavioral health inpatient facility.

C. An administrator shall:

1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,

2. Make any repairs or corrections stated on the fire inspection report, and

3. Maintain documentation of a current fire inspection.

Notes

Ariz. Admin. Code § R9-10-322

Section R9-10-322, formerly numbered as R9-10-233, renumbered as an emergency effective February 22, 1979, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 79-1). Adopted effective June 14, 1979 (Supp. 79-3). Former Section R9-10-322 repealed, new Section R9-10-322 adopted effective February 4, 1981 (Supp. 81-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-322made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014. Amended by final expedited rulemaking at 25 A.A.R. 3481, effective 11/5/2019.