| (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 (5) the EMS provider is found to have committed any of the violations, outlined in §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License) that serves as a basis for such department disciplinary actions as: a reprimand, a monetary administrative penalty assessment, EMS provider license suspension, probated suspension of an EMS provider license, revocation of license, emergency suspension of license. (j) Appeal Procedure for Proposed Denial, Probated Suspension, Suspension, or Revocation of CCMP Approval. (1) If the department proposes to deny, suspend, or revoke its approval given for an EMS provider to conduct a CCMP, the department will send written notification of such to the EMS provider's last known address as shown in the current records of the department. The notice will state the alleged facts or conduct to warrant the proposed action and state that the EMS provider may request an administrative hearing. (2) An EMS provider's request for an administrative appeal hearing to contest the proposed action shall be in writing and submitted to the department within 15 days after the date that the department sent written notice to the EMS provider of the department's proposed action. The appeal hearing shall be conducted pursuant to the Administrative Procedure Act, Government Code, Chapter 2001. (3) If the department does not receive a written notice of its request for an administrative appeal hearing from the EMS provider by the 15th day after the date the department sent written notice to the EMS provider of the department's proposed action, the EMS provider is deemed to have waived the opportunity for a hearing and the department may take the proposed action. (k) Probation. The department may probate the suspension of approval of a CCMP and specify terms and conditions of any probated suspension accessed. (l) Surrender of CCMP Approval. (1) An EMS provider shall use a department approved surrender form to document its surrender to the department of its CCMP approval. (2) An EMS provider's surrender of a CCMP approval to the department shall not deprive the department of jurisdiction in regard to any disciplinary action against the EMS provider. (3) In the event that any department proposed disciplinary against the EMS provider is pending or is reasonably imminent, the EMS provider must acknowledge that the surrender of its CCMP approval constitutes a plea of "no contest" to the allegations upon which the proposed disciplinary action is predicated. (m) Reapplication After Surrender, Denial, or Revocation. An EMS provider, whose EMS provider license or approval to conduct a CCMP has either been surrendered while disciplinary action is pending or is reasonably imminent or which has been denied or revoked, cannot apply for, nor receive, approval to conduct a CCMP until 2 years after the date of the denial, revocation or such surrender of the EMS provider license or CCMP approval. An EMS provider who files an application for CCMP approval at least 2 years after the date of such surrender, denial or revocation of its previous EMS provider license or CCMP approval, shall provide evidence, and have the burden to show, that the reasons for the earlier denial, revocation, or such surrender of its previous EMS provider license or CCMP approval, no longer exists. (n) Notification of Disposition. A summary of the department's order, outlining the final disposition of any proposed disciplinary action and the basis for such may be placed upon the department's website. A copy of such order may be sent to the licensed EMS provider, and the medical director. (o) Medical Director Attestation of CCMP Participation. With regard to EMS personnel, employed by or affiliated with an EMS provider having approval to conduct a CCMP, the EMS provider's medical director shall timely provide to such EMS personnel a document, signed and dated by the medical director, attesting to such EMS personnel's participation in that CCMP. (1) The document shall acknowledge that the EMS personnel is currently participating in the CCMP and shall specify the amount of time, including the beginning date that the EMS personnel participated in the CCMP. (2) For those personnel who leave the CCMP the medical director within 30 days of their departure (or sooner, if needed) shall provide to the EMS personnel documentation, attesting to such EMS personnel's participation in that CCMP and attesting to the amount of time, including the beginning date and ending date, that the EMS personnel participated in the CCMP. Cont'd... |
