The Executive Commissioner of the Health and Human Services Commission, on behalf of the Department of State Health Services (department), proposes amendments to §§157.2, 157.5, 157.11 - 157.14, 157.16, 157.32 - 157.34, 157.36, 157.38, 157.43, and 157.44, the repeal of §157.3 and new §157.3, concerning Emergency Medical Services (EMS) provider licensing.

BACKGROUND AND PURPOSE

The rules are necessary to comply with Health and Safety Code, Chapter 773, Subchapter C, which requires the department to issue EMS provider licenses in accordance with this chapter.

Senate Bill (SB) 8 and House Bill 3556, 83rd Legislation, Regular Session, 2013, added Health and Safety Code, §773.05712, which requires licensed EMS providers to declare an Administrator of Record.

SB 1899, 84th Legislation, Regular Session, 2014, added Health and Safety Code, §773.05715 and §773.05716 that requires emergency medical service providers have a permanent physical location as the provider's primary place of business, and to own or hold a long-term lease for its equipment and vehicles.

SB 219, 84th Legislation, Regular Session, 2014, requires changing the name of Emergency Medical Technician-Intermediate (EMT-I) to Advanced Emergency Medical Technician (AEMT). SB 219 also amended Health and Safety Code, Chapter 773 by replacing the outdated references to the "Board of Health" with the rulemaking authority of the "Executive Commissioner" and the "department" due to the 2004 department reorganization.

SB 1574, 84th Legislation, Regular Session, 2014, added Health and Safety Code, §81.012 that requires entities using emergency response employees or volunteers to have a designated infection control officer to deal with employees' exposure to reportable diseases through blood or other body fluids.

These and other rules amendments reflects years of input from Emergency Medical Services (EMS) stakeholders to the Governor's EMS and Trauma Advisory Council (GETAC) on ways to improve the Texas EMS system through rules amendments and provides clarification to current rules.

These proposed rules are the product of more than 15 public, statewide stakeholder meetings between members of the EMS Committee of GETAC and department staff. They represent a grass roots process of feedback and deliberation garnered during more than 100 hours of meetings between emergency medical personnel and state EMS officials. On December 11, 2015, the EMS Committee supported these proposed revisions and made a recommendation to GETAC to support the proposed rules.

The draft rules were reviewed by GETAC at meetings on January 27, 2016 and February 12, 2016, GETAC voted unanimously, recommending the draft rules be proposed to the State Health Services Council.

The purpose of the revisions to the rules is to comply with new legislation and update current rule language to reflect state and national trends. These rules will affect more than 63,000 EMS personnel, 800 EMS Providers and the 4 million patients that the EMS and Trauma system treat and transport annually.

The rules are also in compliance with Government Code, §2001.039, and requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). Sections 157.2, 157.3, 157.5, 157.11 - 157.14, 157.16, 157.32 -157.34, 157.36, 157.38, 157.43, and 157.44 have been reviewed, and the department has determined that reasons for adopting the section continues to exist because rules on this subject are needed.

SECTION-BY-SECTION SUMMARY

Section 157.2, Definitions, incorporates modifications to existing rules by adding several new definitions and updating language and terms to current standards.

Section 157.3, Processing EMS Providers Licenses and Applications for EMS Personnel Certification and Licensure, was repealed and rewritten as a new rule to incorporate modifications to existing rules and update language to current terms and practices. This section rewrite develops and clarifies the time periods by which the department reviews applications for completeness and processes applications to make eligibility determinations of applicants for various EMS certifications, licenses and approvals as required by Texas Government Code, Chapter 2001.

Section 157.5, Rule Exception Requests, incorporates modifications to existing rules to update language in alignment with current terms and practices. Replaces bureau chief with the department and removes EMT-Intermediate and adds Advanced Emergency Medical Technician.

Section 157.11, Requirements for Emergency Medical Services Provider Licensing, incorporates modifications to existing rules to existing language and terms to current standards and practices. Amendments to current rules were also added due to legislation from SB 1899 and SB 1574. The changes required by SB 1899 were based on the ongoing steps being taken to reduce and prevent fraud within the EMS industry in Texas.

Section 157.11(c)(7)(D) prevents entities from adopting a deceptively similar name to an established license EMS Provider, city, county or Regional Advisory Council.

Section 157.11(c)(7)(F) is added language due to legislation from SB 1899 requirements for EMS Providers. This additional requirement mandates an EMS provider declare the address of their main business location, normal business hours, and map of service area. It also stipulates only one EMS Provider per location, and requires the provider to retain at that location until the next licensing period, unless otherwise approved by the department.

Section 157.11(c)(7)(G) outlines the education requirements for the administrator of record (AOR), per SB 8, 83rd Legislature, Regular Session, 2013, requirement for additional education and continuing education for AORs.

Section 157.11(c)(7)(J) provides the department with a staffing plan that addresses coverage of a service area which includes a process to manage communication after normal business hours have concluded.

Section 157.11(c)(7)(O) states that an EMS provider must provide the department with a list of equipment with identifiable or legible serial numbers at the initial or renewal application for an EMS Provider license.

Section 157.11(c)(7)(Q) states that an EMS provider must attest that each authorized vehicle has its own set of required equipment.

Section 157.11(c)(7)(S) states that an EMS provider will attest or provide documentation that the applicant and/or its management staff participates in the local regional advisory council.

Section 157.11(e)(3) states that ambulance vehicles must meet minimum national ambulance vehicle body type, dimension and safety criteria standards.

Section 157.11(g)(3) states that the staffing plan requires proof that the personnel has completed a jurisprudence examination.

Section 157.11(j)(2) requires that all patient equipment shall be clean and fully operational and have a backup power source, if applicable.

Section 157.11(k)(1) - (3) explains what kind of patients and at what level of care is expected to be provided by each type of ambulance.

Section 157.11(k)(2)(F) requires waveform capnography be used when preforming or monitoring endotracheal intubation patients as of January 1, 2018, which is the standard throughout the nation.

Section 157.11(k)(3)(C) requires an active 12-lead capability cardiac monitor/defibrillator by January 1, 2020, which is the standard throughout the nation.

Section 157.11(m)(1)(C) requires an EMS provider, who is not the primary provider in an area where it plans to sell subscriptions, to provide to subscription plan participants a written notice that it is not the primary provider in that area and additionally requires said provider to provide a copy of this notice to the primary provider in the area and to the department within 30 days before it begins its subscription enrollment period.

Section 157.11(n) requires an EMS provider have a plan in place for the ongoing monitoring of patient care quality provided by the EMS provider's personnel and the collection of patient care data as required by 25 Texas Administrator Code, Chapter 103, concerning the reporting requirements for EMS providers.

Section 157.11(n)(15) sets standards for the maintenance and location of medical records.

Section 157.11(n)(27)(F) as required by U.S. Code, Title 42, Chapter 6A, Subchapter XXIV, Part G, each EMS Provider must have an educated designated infection control officer to enhance communication between hospitals and the EMS Provider.

Section 157.11(n)(27)(J) requires a policy explaining the process to secure medications, fluids and controlled substances on ambulances which are in compliance with local, state, and federal laws and rules.

Section 157.11(p) states that a provisional license shall be effective for no more than "30 days" instead of "45 days" from the date of issuance.

Section 157.11(r) outlines the process that the department will use to conduct surveys, inspections and investigations.

Section 157.11(u) outlines the process that the department will use when conducting a complaint investigation.

Section 157.12, Rotor-wing Air Ambulance Operations, and 157.13, Fixed-wing Air Ambulance Operations, incorporate modifications into existing rules, bringing language and terms up to current standards to include ensuring the air unit meets air worthiness stats per federal regulations. Changes include documentation of the knowledge and experiences of the medical director when treating and transporting patients by air. Also, includes the removal of language stipulating bodily injury and property damage insurance coverage amounts for the aircraft provider as these amounts are already set by federal regulations. Adds language requiring permanently installed climate control equipment to provide an environment appropriate for the medical needs of patients.

Section 157.14 adds requirements for a First Responder Organization License (FRO) to include incorporation of U.S. Code, Title 42, Chapter 6A, Subchapter XXIV, Part G, §300ff-136 and SB 1574 requirements for the designation of an infection control officer. Additionally, it requires that FRO License applications include response, dispatch and treatment protocols including an equipment and supply list to treat adult, pediatric and neonatal patients.

Section 157.16, Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License, incorporates modifications into existing rules, adds language and terms to include allowing the department to take disciplinary action based on action taken by other states or federal agencies. Additional modification includes notifying the AOR and the EMS Provider license holder of pending disciplinary action by the department.

Section 157.32, Emergency Medical Services Education Program and Course Approval, incorporates modifications into existing rules to meet current national education standards by increasing the minimum required hours needed to complete an Emergency Care Attendant course, an EMT-Basic course, an Advanced EMT course and a EMT-Paramedic course. An additional amendment was included to change the name of the "Intermediate EMT-I" to "Advanced EMT" which was changed by SB 219 and reflects a national name change.

Language was added in §157.32(d)(2)(C) to ensure that the sponsor of an education program has the required equipment and resources to conduct the program.

Language was added as required by U.S. Code, Title 42, Chapter 6A, subchapter XXIV, Part G, stipulating each EMS Provider must have an educated designated infection control officer to enhance communication between program, hospitals and the student taking the program.

Section 157.32(i)(2)(A) provides detailed information on what the department expects to be provided when receiving a self-study submitted by the applicant. Throughout this rule language was added to ensure medical oversight must be involved in all aspects of the education program.

Section 157.32(p)(25) was added to ensure online or distance learning classes must meet the same standards as outlined in this rule.

Section 157.33, Certification, incorporates modifications to existing rule language and terms to reflect current standards and includes provisions requiring fingerprinting of EMS personnel as directed in Government Code, §411.087 and §411.110 and as required in §157.37 relating to Certification or Licensure of Persons with Criminal Backgrounds. The following responsibilities included for EMS personnel were also added:

- to complete an accurate patient care record;

- to report abuse or injury to a patient;

- to follow the medical director's protocols and policies;

- take precautions to prevent misappropriation of medication, maintain skills and knowledge of level of certification; and

- to notify the department within 30 days of a change of address.

Section 157.34, Recertification, incorporates modifications into existing rule language and terms to reflect current standards and includes the EMS jurisprudence exam as required by SB 1899. The Advanced EMT replaced the EMT-I in this rule.

Section 157.36, Criteria for Denial and Disciplinary Actions for EMS Personnel and Applicants and Voluntary Surrender of a Certificate or License, incorporates modifications into existing rules by clarifying current language and adding additional actions the department may take, including disciplinary actions against EMS personnel certification. Disciplinary action may be taken by the department against a person's certification or license for the following additional reasons:

- failing to report abuse or injury to a patient to employer or legal authority within 24 hours;

- turning over or delegating care to person whom has the lacks of education or skills to treat the patient at the appropriate level required;

- failing to take precautions to prevent misappropriation of medication;

- cheating on a test to gain or renew certification/license by department;

- using drugs or alcohol that could possibly endanger patient health and safety;

- failing to transport the patient to an appropriate medical facility;

- failing to contact medical control when required;

- falsifying an employment application that would affect the hiring process;

- falsifying clinical documentation as a student;

- falsifying required daily check sheets;

- engaging in act(s) of dishonesty which relates to the EMS profession,

- behavior exploiting the EMS personnel- patient relationship in a sexual way;

- falsifying information provided to the department;

- engaging in a pattern of behavior that demonstrates routine response to medical emergencies without being under the medical oversite or with an EMS Provider or FRO; and

- disciplinary action taken by another state, U.S. territory, National Registry of EMT or any other national recognized organization that provides or renews certification/license.

Section 157.38, Continuing Education, incorporates modifications into existing rule language and terms to reflect current standards. It requires a continuing education program to designate an infection control officer and to verify that it has physician medical oversight when its students are involved with patient care.

Section 157.43, Course Coordinator Certification, incorporates modifications into existing rule language by increasing the teaching experience requirement for a course coordinator to four years of experience in EMS. It also ensures physician medical oversight when education is conducted, especially when performing clinic time or advance level skills within an ambulance. Language was also added to require more detail be provided to students regarding what to expect from an EMS education program, and what is required to gain certification/license in Texas. It also requires education to be provided to all students regarding current Texas EMS laws, rules and policies, per SB 1899.

Section 157.43(h)(20) requires that a course coordinator notify the department when leaving as the course coordinator for an ongoing EMS education program.

Section 157.43(m)(3)(AA) explains what is considered unprofessional conduct by the department such as retaliation; discrimination; and verbal or physical abuse; or inappropriate physical or sexual conduct.

Section 157.44(f), Emergency Medical Service Instructor Certification, incorporates modifications to existing rules by requiring an EMS Instructor to document at least 8 hours every two years of providing or observing EMS care being giving in an ambulance, hospital or clinic to enhance and reinforce the instructors' knowledge of the Texas EMS system.

Section 157.44(i)(2)(W) and (X) allows the department to take disciplinary action against an instructor for failing to notify the department if the instructor learns of a student applicant that was arrested, convicted, had deferred adjudication or deferred prosecution.

Section 157.44(i)(2)(Y), provides what is considered unprofessional conduct by the department such as retaliation; discrimination; verbal or physical abuse; or inappropriate physical or sexual conduct.

FISCAL NOTE

Mr. Joseph Schmider, Office of EMS/Trauma Systems Coordination, has determined that for each year of the first five years that the sections will be in effect, there will be no fiscal implications to state government but there will be minimal fiscal implications to local governments (such as cities or counties) as a result of enforcing and administering the sections as proposed. During more than 15 statewide stakeholder meetings, the department conducted informal surveys and determined that a large majority of the current EMS Providers already carry this additional new equipment.

SMALL AND MICRO-BUSINESS IMPACT ANALYSIS AND ECONOMIC COSTS TO PERSONS

Mr. Schmider has also determined that there will be an adverse impact on small businesses or micro-businesses or persons who are required to comply with the rules as proposed. These rules will implement new requirements for applicants seeking to gain and maintain an EMS provider license or EMS providers renewing license or certification in Texas, these additional requirements are the following:

- ongoing cost for eight hours per year of continuing education for an EMS Provider's Administrator of Record;

- EMS personnel will have to complete a jurisprudence examination as required in SB 1899, and is expected to be around $40 per person every four years;

- the purchase of a waveform capnography for each advance life support ambulance that performs endotracheal intubation by January 1, 2018, with the cost range between $1500 to $3000 per unit; and

- the purchase of an active 12-lead capability cardiac monitor/defibrillator for each advance life support ambulance by January 1, 2020, with the cost range between $4000 to $10,000 per device.

IMPACT ON LOCAL EMPLOYMENT

There is no anticipated negative impact on local employment.

PUBLIC BENEFIT