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RULE §157.39Comprehensive Clinical Management Program Approval

    (D) have completed a department-approved CCMP survey course and/or participation in a survey internship.

  (8) The department at its discretion may exempt survey team members from having to meet the requirements noted in paragraph (7)(A), (B) or (C) of this subsection, if the number of qualified survey team members in the applicant's general geographical area is inadequate to form a survey team. The CCMP survey organization must make a written request showing sufficient cause for the department to grant an exemption.

  (9) The survey organization with its survey team members shall professionally and accurately evaluate and make written findings of the EMS provider's ability to effectively meet and maintain CCMP standards described in subsection (h) of this section.

(g) Survey Documentation and Reporting Timetable.

  (1) The survey organization shall utilize the department's CCMP survey form and shall provide the department and the provider with an accurate and complete written survey report, signed by all survey team members, regarding its evaluation of the applicant's compliance with CCMP standards, no later than 30th calendar day after the completion date of the survey.

  (2) The CCMP survey(s), and the resulting survey documentation, and the applicant's CCMP survey organization's submission of the survey report and related documentation to the department shall be completed no later than two years after the date the department sent notice to the applicant that its application was accepted for filing. Failure to timely complete all of the above within two years from the date that the department sent notice to the applicant that its application was accepted for filing will be deemed to be a withdrawal of the EMS provider's application for CCMP approval.

  (3) The department reserves the right to request from the applicant, and the applicant shall be obligated to produce no later than the 10th day after having received such request, true and correct copies of any survey reports that the applicant received from its survey organization related to any initial surveys, conducted prior to any final survey.

  (4) CCMP Final Survey Report. The survey report, completed by the department recognized CCMP survey organization, shall accurately document the survey organization's findings and its evaluation of the EMS provider's ability to effectively meet the minimum standards required to obtain and to maintain CCMP department approval as outlined in subsection (h) of this section.

(h) CCMP Minimum Standards. To receive and maintain department approval to conduct a CCMP, an EMS provider shall:

  (1) assure that an initial assessment of new EMS personnel has been conducted by providing documentation of:

    (A) a written assessment of didactic knowledge evaluation, specific to the certification level of the applicant and focusing on the clinical information (evaluation cannot be the department or NREMT exam, and should utilize numeric scoring - not pass/fail - to assess individuals' level of preparedness);

    (B) a situation-based practical evaluation;

    (C) a background investigation process of EMS personnel, which includes verification of certification/licensure and administrative/disciplinary history through the department, work history and driving record;

    (D) a detailed job description; and

    (E) a screening process to ensure the minimum requirements are met, and which includes significant medical director involvement.

  (2) credential EMS personnel by providing documentation of:

    (A) a state certification/licensure verification process;

    (B) a process for EMS personnel to demonstrate skills proficiency to the satisfaction of the medical director;

    (C) a process for reintegration (i.e. bringing an individual from inactive or administrative status back into active practice in the field);

    (D) a process for bi-annual field evaluation by a preceptor (field training officer or similar position) which includes demonstration of adequate patient care and scene control skills, appropriate conduct for EMS personnel, etc.; and

    (E) a policy that defines the EMS personnel covered by the CCMP program (only individuals credentialed by the medical director will be eligible for renewal through §157.34(b)(5) of this title).

  (3) assure and maintain a preceptor selection, development and training process; developed with the medical director's input and approval.

  (4) assure EMS personnel internship by providing documentation of:

    (A) a process in which interns ride as a third person until the preceptor establishes the intern has met pre-established competencies as defined by the medical director;

    (B) a process in which interns ride as the second person until the preceptor establishes the intern has met prerequisites for independent duty as determined by the medical director;

    (C) a process in which the intern must demonstrate proficiency to at least two different preceptors;

    (D) a process in which the intern evaluates the internship program; and

    (E) a process in which the medical director reviews and ensures that all predetermined competencies are met before being released from internship.

  (5) assure and maintain professional development of EMS personnel by maintaining and providing documentation:

    (A) of professional development training of EMS personnel in the following amounts per year: EMT-P--24 hours, EMT-I--20 hours, EMT--16 hours, ECA--10 hours;

    (B) that other staff (flight nurses and communications personnel) are required to obtain at least the minimum continuing education hours as directed by the appropriate certifying or licensing authority;

    (C) that EMS personnel receive continuing education on at least a semiannual or quarterly basis;

    (D) that the continuing education instruction spans the three learning domains which include cognitive, affective and psychomotor;

    (E) that demonstrates programmatic strengths and performance improvement plans for weaknesses;

    (F) that the continuing education clinical content is defined and approved by the medical director;

    (G) that 50% of the continuing education is in-person training; and

    (H) of consistent instructional delivery by all instructors.

  (6) assure and maintain protocol/standard of care management by providing documentation of:

    (A) ongoing protocol review, updated according to current literature, practice techniques, executed and approved by the medical director;

    (B) a process for assessing the relative benefit from protocol revisions;

    (C) a process for protocol knowledge assessment among EMS personnel protocol assessment that reflects the ongoing protocol review and revision, with structure and content defined and approved by the medical director, and a defined remediation process with established timelines;

    (D) a process for protocol criteria to be jointly defined by the medical director and EMS provider administration; and

    (E) a reassessment/re-education process and timeline that clearly identifies the criteria for identification of weakness and successful completion of re-education; or revocation of credentials if unsuccessful.

  (7) assure and maintain a quality improvement program by providing documentation of:

    (A) a five component problem-solving process with the following components: assessment, goal setting, plan development, intervention, and progress evaluation;

    (B) an assessment of the provider's daily activities;

    (C) measurable clinical indicators that are regularly assessed for compliance with established thresholds;

    (D) an appropriate, organized and prioritized monitoring and evaluation system for compliance with documentation standards, correct protocol selection and appropriate patient care;

    (E) assessment of key performance indicators such as personnel/staffing, response and averaging with correct statistical monitoring, clinical care (skills performance, protocol selection, patient assessment, etc.), customer relations program, education, administrative/operational policies;

    (F) a monthly random chart review of all runs (at least 5% or 30, whichever is greater) for compliance with documentation standards, correct protocol selection, and appropriate patient care;

    (G) an annual cardiac arrest survival analysis in accordance with current acceptable criteria; and

    (H) tracking individual performance of skills (5 minimum), appropriate for that level of certification or licensure, for each EMS personnel.

  (8) assure and maintain a complaint resolution process/management by providing documentation of:

    (A) a centralized location for receiving complaints;

    (B) an established triage process to appropriately direct complaint resolution to potential disciplinary or quality improvement avenues;

    (C) a process that ensures the timely reporting of any rule or law violations to appropriate licensing and government authorities; and

    (D) a process to track/trend the nature of each complaint and feed data into a quality improvement program.

  (9) assure and maintain a system to respond to sentinel event response process/management; by providing documentation of:

    (A) a process to appropriately direct the response to emergency problems such as equipment failures, supply deficiency, medication errors, fleet failures, etc.;

    (B) appropriate record-keeping and tracking of sentinel events; and

    (C) a process to investigate sentinel events which involves the appropriate parties.

  (10) assure and maintain an ongoing corrective action process by providing documentation of:

    (A) annual documentation of the results of the quality improvement efforts and formal complaint tracking process, including content of continuing education or individual training sessions to resolve identified deficiencies;

    (B) evidence to resolve and reassess identified deficiencies;

    (C) a process to determine whether deficiencies are individual or system oriented;

    (D) a developed reporting structure that includes a public performance report;

    (E) a policy and methods regarding privilege/confidentiality;

    (F) a process of remediation and improvement strategies which comply with DSHS continuing education requirements, as appropriate; and

    (G) evidence of medical director involvement in the process.

  (11) assure committee(s) are established and maintained to identify, plan, implement and evaluate opportunities to improve performance in all areas of the EMS system.

  (12) assure that the medical director qualifications, experience, involvement and responsibilities are maintained by providing documentation that the medical director:

    (A) is registered as the EMS provider's medical director with the department;

    (B) meets requirements of 22 TAC, Chapter 197 (relating to Emergency Medical Service) of the Texas Medical Board;

    (C) is an active participant in the local Regional Advisory Committee; and

    (D) has completed a course in EMS medical direction.

  (13) assure that the CCMP coordinator qualifications, experience, involvement and responsibilities are maintained by providing documentation that:

    (A) the CCMP coordinator is responsible for the administrative functions of the CCMP program;

    (B) the dedication of staff time is sufficient to fulfill the programmatic requirements of the CCMP;

    (C) a CCMP organizational chart clearly describes the administrative reporting structure of the CCMP program;

    (D) there is evidence to demonstrate that quality improvement experience and/or training is sufficient to implement and maintain CCMP standards; and

    (E) shall complete a department approved CCMP workshop of at least 8 hours.

(i) Probation, Suspension, Revocation or Denial of Initial or Renewal CCMP Approval. The department may probate, suspend, revoke, or deny initial or renewal approval for an EMS provider to conduct a CCMP for, but not limited to, the following noted reasons:

  (1) the EMS provider fails to meet or maintain the CCMP minimum standards or the eligibility requirements, outlined in this section;

  (2) the EMS Provider fails to meet or maintain those responsibilities required or standards, outlined in §157.11 of this title (relating to Requirements for an EMS Provider);

  (3) the EMS provider falsifies or makes misrepresentations in any documentations communications regarding its applications seeking department approval to conduct a CCMP;

  (4) the provider falsifies or makes misrepresentations in any documentations or communications regarding its conducting a CCMP; or


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