The hospital has a comprehensive emergency management program that utilizes an all-hazards ap...

(1)

The hospital has a written comprehensive emergency management program that utilizes an all-hazards approach. The program includes, but is not limited to, the following: - Leadership structure and program accountability - Hazard vulnerability analysis - Mitigation and preparedness activities - Emergency operations plan and policies and procedures - Education and training - Exercises and testing - Continuity of operations plan - Disaster recovery - Program evaluation

(2)

If the hospital is part of a health care system that has a unified and integrated emergency management program and it chooses to participate in the program, the following must be demonstrated within the coordinated emergency management program: - Each separately certified hospital within the system actively participates in the development of the unified and integrated emergency management program - The program is developed and maintained in a manner that takes into account each separately certified hospital’s unique circumstances, patient population, and services offered - Each separately certified hospital is capable of actively using the unified and integrated emergency management program and is in compliance with the program - Documented community-based risk assessment utilizing an all-hazards approach - Documented individual, facility-based risk assessment utilizing an all-hazards approach for each separately certified hospital within the health care system - Unified and integrated emergency plan - Integrated policies and procedures - Coordinated communication plan - Training and testing program

(3)

The hospital complies with all applicable federal, state, and local emergency preparedness laws and regulations.

(4)

For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant programs (as defined in 42 CFR 482.70), the following must occur: - A representative from each transplant program must be included in the development and maintenance of the hospital's emergency preparedness program - The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant program, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency