A hospice care center applicant or licensee must:

(1) Develop and operationalize written policies and procedures governing emergency preparedness and fire protection;

(2) Develop a written emergency preparedness plan, rehearsed at least annually with personnel, contractors, and volunteers that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal facility operation. Include, at minimum: Risk assessment and emergency planning, communication plan, subsistence needs, evacuation plans, sheltering in place, care of casualties, tracking patients and staff during an emergency, and staff training and drills to test emergency plan; and

(3) Develop a fire protection plan to include:

(a) Instruction for all personnel, contractors or volunteers in use of alarms, firefighting equipment, methods of fire containment, evacuation routes and procedures for calling the fire department and the assignment of specific tasks to all personnel, contractors and volunteers in response to an alarm; and

(b) Fire drills for each shift of personnel.