| (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;
Cont'd... |
