§ 71541. Fire and Internal Disasters.

(a) A written fire and internal disaster program, incorporating evacuation procedures, shall be developed with the assistance of fire, safety and other appropriate experts. A copy of the program shall be available on the premises for review by the Department.

(b) The written program shall include at least the following:

(1) Plans for the assignment of personnel to specific tasks and responsibilities.

(2) Instructions relating to the use of alarm systems and signals.

(3) Information concerning methods of fire containment.

(4) Systems for notification of appropriate persons.

(5) Information concerning the location of fire fighting equipment.

(6) Specification of evacuation routes and procedures.

(7) Other provisions as the local situation dictates.

(c) Fire and internal disaster drills shall be held at least quarterly, for each shift of hospital personnel and under varied conditions. The actual evacuation of patients to safe areas during a drill is optional.

(d) The evacuation plan shall be posted throughout the facility and shall include at least the following:

(1) Evacuation routes.

(2) Location of fire alarm boxes.

(3) Location of fire extinguishers.