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A facility, with the exception of home health agencies and hospice agencies that do not provide inpatient care on agency premises, must have a risk management program that has

(1) provision for monitoring, evaluating, identifying, correcting, and reassessing care practices that negatively affect quality of care and services provided or result in accident or injury to a patient, resident, or staff, and provisions for documenting deficiencies found and remedial actions taken;

(2) a preventive maintenance program that is designed to ensure the proper functioning, safety and performance of all electrical and mechanical equipment used in the care, diagnosis, and treatment of patients or residents, and for the physical plant including the electrical, plumbing, heating, and ventilation systems and their parts, including

(A) implementation of policies that specify procedures and frequencies for the maintenance of all equipment and systems and all their parts, that meets or exceeds manufacturers’ recommendations; and

(B) documentation of the preventive maintenance that has occurred;

(3) a procedure to investigate, analyze, and respond to patient or resident grievances that relate to patient or resident care;

(4) a job-specific orientation program and an in-service training program for each employee that provides annual instruction in

(A) policies and procedures for that service;

(B) the employee’s job responsibilities and the skills necessary to meet those responsibilities;

(C) safety, fire, and disaster plans; and

(D) principles and techniques of infection control;

(5) provision of 24-hour emergency service by a physician, on site or on call, including posting the on-call physician’s name and phone number at each nursing station; a frontier extended stay clinic or free-standing birth center is exempt from the requirements of this paragraph;

(6) quarterly fire drills for each work shift, a record showing when each drill was held, and coordination with community or area mass casualty drills;

(7) an annual review of written policies and procedures approved, signed, and dated by the administrator or the administrator’s designee;

(8) a training program by an instructor certified in cardiopulmonary resuscitation (CPR) for all personnel who are engaged in patient care; the training program must include certification of employees by an approved organization;