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RULE §157.11Requirements for an EMS Provider License

  (2) each EMS provider shall develop, implement, maintain, and evaluate an effective, ongoing, system-wide, data-driven, interdisciplinary quality assessment and performance improvement program. The program shall be individualized to the provider and shall, at a minimum, include:

    (A) the standard of patient care as directed by the medical director's protocols and medical director input into the provider's policies and standard operating procedures;

    (B) a complaint management system;

    (C) monitoring the quality of patient care provided by the personnel and taking appropriate and immediate corrective action to insure that quality of care is maintained in accordance with the existing standards of care and the provider medical director's signed, approved protocols;

    (D) the program shall include, but not be limited to, an ongoing program that achieves measurable improvement in patient care outcomes and reduction of medical errors;

  (3) provide an attestation or provide documentation that its management staff will or continue to participate in the local regional advisory council;

  (4) when an air ambulance is initiated through any other method than the local 911 system the air service providing the air ambulance is required to notify the local 911 center or the appropriate local response system for the location of the response at time of launch. This would not include interfacility transports or schedule transports;

  (5) ensuring that all personnel are currently certified or licensed by the department;

  (6) assuring that all personnel, when on an in-service vehicle or when on the scene of an emergency, are prominently identified by, at least, the last name and the first initial of the first name, the certification or license level and the EMS provider's name. A provider may utilize an alternative identification system in incident specific situations that pose a potential for danger if the individuals are identified by name;

  (7) assuring the confidentiality of all patient information is in compliance with all federal and state laws;

  (8) assuring that Informed Treatment/Transport Refusal forms are signed by all persons refusing service, or documenting incidents when a signed Informed Treatment/Transport Refusal form cannot be obtained;

  (9) assuring that patient care reports are completed accurately for all patients and meet standards as outlined in 25 Texas Administrative Code, Chapter 103;

  (10) assuring that patient care reports are provided to facilities receiving the patient:

    (A) whenever operationally feasible, the report shall be provided to the receiving facility at the time the patient is delivered or a full written or computer generated report shall be delivered to the facility within 24 hours of the delivery of the patient,

    (B) if in a response-pending status, an abbreviated documented report shall be provided at the time the patient is delivered and a completed written or computer generated report shall be delivered to the facility within 24 hours of the delivery of the patient;

    (C) the abbreviated report shall document, at a minimum, the patient's name, patient's condition upon arrival at the scene; the prehospital care provided; the patient's condition during transport, including signs, symptoms, and responses to treatment during the transport; the call initiation time; dispatch time; scene arrival time; scene departure time; hospital arrival time; and, the identification of the ambulance staff; and

    (D) in lieu of subparagraph (C) of this paragraph, personnel may follow the Regional Advisory Council's process for providing abbreviated documentation to the receiving facility.

  (11) assuring that all pharmaceuticals are stored according to conditions specified in the pharmaceutical storage policy approved by the EMS provider's medical director;

  (12) assuring that staff completes a readiness inspection as written by the EMS provider's policy;

  (13) assuring that there is a preventive maintenance plan for vehicles and equipment.

  (14) assuring that staff has reviewed policies and procedures as approved by the EMS Provider and the EMS Provider Medical Director;

  (15) Maintenance of medical reports.

    (A) A licensed EMS provider shall maintain adequate medical reports of a patient for a minimum of seven years from the anniversary date of the date of last treatment by the EMS provider.

    (B) If a patient was younger than 18 years of age when last treated by the provider, the medical reports of the patient shall be maintained by the EMS provider until the patient reaches age 21 or for seven years from the date of last treatment, whichever is longer.

    (C) An EMS provider may destroy medical records that relate to any civil, criminal or administrative proceeding only if the provider knows the proceeding has been finally resolved.

    (D) EMS providers shall retain medical records for a longer length of time than that imposed herein when mandated by other federal or state statute or regulation.

    (E) EMS providers may transfer ownership of records to another licensed EMS provider only if the EMS provider, in writing, assumes ownership of the records and maintains the records consistent with this chapter.

    (F) Destruction of medical records shall be done in a manner that ensures continued confidentiality.

    (G) At the time of initial licensing and at each license renewal, the EMS provider and medical director must attest or provide documentation to the department a plan for the going out of business, selling, transferring the business to ensure the maintenance of the medical record as outlined in subparagraph (E) of this paragraph.

    (H) The emergency medical services provider must maintain all patient care records in the physical location that is the provider's primary place of business, unless the department approves an alternate location.

  (16) assuring that all requested patient records are made promptly available to the medical director, hospital or department when requested;

  (17) assuring that current protocols, equipment, supply and medication lists, and the correct original Vehicle Authorization at the appropriate level are maintained on each response-ready vehicle;

  (18) monitoring and enforcing compliance with all policies and protocols;

  (19) assuring provisions for the appropriate disposal of medical and/or biohazardous waste materials;

  (20) assuring ongoing compliance with the terms of first responder agreements;

  (21) assuring that all documents, reports or information provided to the department and hospital are current, accurate and complete;

  (22) assuring compliance with all federal and state laws and regulations and all local ordinances, policies and codes at all times;

  (23) assuring that all response data required by the department is submitted in accordance with §103.5 of this title (relating to Reporting Requirements for EMS Providers);

  (24) assuring that, whenever there is a change in the EMS provider's name or the service's operational assumed name, the printed name on the vehicles are changed accordingly within 30 days of the change;

  (25) assuring that the department is notified within 30 business days whenever:

    (A) a vehicle is sold, substituted or replaced;

    (B) there is a change in the level of service;

    (C) there is a change in the declared service area as written on an initial or renewal application;

    (D) there is a change in the official business mailing address;

    (E) there is a change in the physical location of the business and/or substations;

    (F) there is a change in the physical location of patient report file storage, to assure that the department has access to these records at all times; and

    (G) there is a change of the administrator of record.

  (26) assuring that when a change of the medical director has occurred the department is notified within one business day;

  (27) develop, implement and enforce written operating policies and procedures required under this chapter and/or adopted by the licensee. Assure that each employee (including volunteers) is provided a copy upon employment and whenever such policies and/or procedures are changed. A copy of the written operating policies and procedures shall be made available to the department on request. Policies at a minimum shall adequately address:

    (A) personal protective equipment;

    (B) immunizations available to staff;

    (C) infection control procedures;

    (D) management of possible exposure to communicable disease;


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