Ariz. Admin. Code § R9-10-523 - Emergency and Safety Standards

A. 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. A floor plan of the facility showing emergency protection equipment, evacuation routes, and exits;

b. When, how, and where residents will be relocated, including:

i. Instructions for the evacuation or transfer of residents,

ii. Assigned responsibilities for each employee and personnel member, and

iii. A plan for continuing to provide services to meet a resident's needs;

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

d. A plan for back-up power and water supply;

e. A plan to ensure a resident's medications will be available to administer to the resident during a disaster;

f. A plan to ensure a resident is provided nursing services, rehabilitation services, and other services required by the resident during a disaster; and

g. A plan for obtaining food and water for individuals present in the ICF/IID or the ICF/IID's relocation site during a disaster;

2. Personnel members receive training on the content and use of the disaster plan required in subsection (A)(1);

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

4. Documentation of a disaster plan review required in subsection (A)(3) 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, or volunteer participating in the disaster plan review;

c. A critique of the disaster plan review; and

d. If applicable, recommendations for improvement;

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

6. An evacuation drill for employees is conducted on each shift at least once every three months and documented;

7. An evacuation drill for residents:

a. Is conducted at least once each year on each shift and documented; and

b. Includes all residents on the premises except for:

i. A resident whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident, and

ii. Sufficient personnel members to ensure the health and safety of residents not evacuated according to subsection (A)(7)(b)(i);

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

a. The date and time of the evacuation drill;

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

c. If applicable:

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

ii. An identification of residents who were not evacuated;

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

e. Recommendations for improvement, if applicable; and

9. An evacuation path is conspicuously posted on each hallway of each floor of the ICF/IID.

B. An administrator shall ensure that, if an ICF/IID has:

1. More than 16 residents or a resident who has a medical care plan or whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident:

a. A fire alarm system is installed according to the National Fire Protection Association 72: National Fire Alarm and Signaling Code, incorporated by reference in R9-10-104.01, and is in working order; and

b. A sprinkler system is installed according to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, incorporated by reference in R9-10-104.01, and is in working order; and

2. Sixteen or fewer residents, none of whom have a medical care plan or whose medical record contains documentation that evacuation from the ICF/IID would cause harm to the resident:

a. A fire alarm system and a sprinkler system meeting the requirements in subsection (B)(1) are installed and in working order; or

b. The ICF/IID has:

i. A fire extinguisher that is:

(1) Labeled as rated at least 2A-10-BC by the Underwriters Laboratories;

(2) Accessible to personnel members and inaccessible to residents;

(3) If a disposable fire extinguisher, replaced when its indicator reaches the red zone; and

(4) If a rechargeable fire extinguisher, is serviced at least once every 12 months, as documented by a tag attached to the fire extinguisher that specifies the date of the last servicing and the identification of the person who serviced the fire extinguisher; and

ii. Smoke detectors that are:

(1) Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer;

(2) Either battery operated or, if hard-wired into the electrical system of the ICF/IID, has a back-up battery;

(3) In working order; and

(4) Tested at least once a month, with documentation of the test maintained for at least 12 months after the date of the test.

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.

D. An administrator shall ensure that, if applicable, a sign is placed at the entrance to a room or area indicating that oxygen is in use.

Notes

Ariz. Admin. Code § R9-10-523

Adopted by final rulemaking at 25 A.A.R. 1222, effective 4/25/2019. Amended by exempt rulemaking at 26 A.A.R. 72, effective 1/1/2020.