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RULE §157.39Comprehensive Clinical Management Program Approval

    (B) have been timely re-surveyed by a department recognized CCMP survey organization, in advance to allow for report submission described in subparagraph (C) of this paragraph; and

    (C) ensure that the CCMP survey organization, that has conducted the survey, has filed with the department and that the department has received from the survey organization a complete survey report.

  (2) If a renewal applicant meets the requirements in subsection (1) of this section no later than the 120th day prior to the expiration date of its existing CCMP approval, the existing CCMP approval does not expire until the applicant's eligibility for renewal of its CCMP approval has been finally determined, as described in Texas Government Code, §2001.054. If the department provides the applicant with a written notice proposing the denial of its renewal application or placement of limitations upon the renewal of approval, and if the department timely receives from the applicant a written request for an administrative appeal hearing to contest the proposed denial or limitation, the existing CCMP approval does not expire until the last day for the applicant to seek a state district court judicial review of the agency order or a later date fixed by order of the reviewing court.

  (3) If a renewal applicant fails to meet the requirements in subsection (1) of this section, no later than 120 days prior to the expiration date of its existing CCMP approval, the existing CCMP approval expires on its expiration date.

  (4) Any EMS personnel that are participating in the applicant's existing CCMP may lose their eligibility to renew their individual EMS certifications or licenses under §157.34(b)(5) of this title, after the expiration date of the existing approved CCMP within which the EMS personnel are participating. If a CCMP approval expires, as set forth in paragraphs (2) or (3) of this subsection, EMS personnel who continue to participate with that CCMP after its expiration date will no longer be allowed credit toward continuing education hours needed for certification or licensure renewal, unless approved by the department.

(f) CCMP Survey.

  (1) The applicant shall seek review and approval of its self-study by a department recognized CCMP survey organization.

  (2) The applicant shall notify the department of the date the survey will begin, the name of the CCMP survey organization, the composition of the survey team, and the names of the survey team members, no later than the 30th day prior to the date the CCMP survey will begin.

  (3) The applicant shall be responsible for any cost and expenses associated with the survey.

  (4) The department, at its discretion, may assign a department staff member and/or appoint an observer to accompany the survey team.

  (5) The survey team shall contain members that have a multi-disciplinary background to include at a minimum: one EMS medical director, one EMS educator and one EMS administrator. The department may require additional surveyors and surveyors with other professional backgrounds, depending upon, but not limited to, the type of EMS provider, the kind of population it serves, and factors noted in the self-study. If such is required, the department will notify the applicant of the additional required surveyors within 20 days after the date that the department has notified the applicant that its application is complete and accepted for filing.

  (6) All members of the survey team, except department staff, shall come from a Trauma Service Area that the applicant is not affiliated with and at least 100 miles from the provider unless otherwise approved by the department at least 20 days before the date the survey is to begin. There shall be no direct business or patient care relationship or any potential conflict of interest between the CCMP survey members, or any of the individual survey members' places of employment or affiliation with a volunteer EMS provider, and the applicant being surveyed. The survey team shall not be composed solely with members from a single EMS provider.

  (7) Department recognized survey organization team members at minimum shall:

    (A) have at least five years experience in active management and leadership of an EMS system using CCMP principles;

    (B) be currently employed with or volunteering for, and be actively managing within an EMS system using CCMP principles;

    (C) have adequate direct experience in assisting an EMS provider in preparing for a CCMP survey and in obtaining CCMP approval; and

    (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


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