The Executive Commissioner of the Health and Human Services Commission (commission), on behalf of the Department of State Health Services (department), adopts 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. The amendments to §§157.2, 157.11 - 157.14, 157.16, 157.32 - 157.34 and new §157.3 are adopted with changes to the proposed text as published in the August 12, 2016, issue of the Texas Register (41 TexReg 5918). The amendments to §§157.5, 157.36, 157.38, 157.43, 157.44 and the repeal of §157.3 are adopted without changes, and therefore, the sections will not be republished.

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 (AOR).

SB 1899, 84th Legislation, Regular Session, 2015, added Health and Safety Code, §773.05715 and §773.05716 that requires emergency medical service providers to have a permanent physical location as the provider's primary place of business, and to own or obtain a long-term lease for its equipment and vehicles.

SB 219, 84th Legislation, Regular Session, 2015, requires changing the name of an Emergency Medical Technician-Intermediate (EMT-I) to an 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 SB 219 also amended Health and Safety Code, Chapter 773 by replacing the outdated references to the "Board of Health" with the rulemaking authority of the "Executive Commissioner" and the "department" due to the department reorganization which occurred in 2004.

SB 1574, 84th Legislation, Regular Session, 2015, added Health and Safety Code, §81.012 that requires entities using emergency response employees or volunteers to have a designated infection control officer to handle an employee's exposure to a reportable diseases through blood or other body fluids.

These and other rules amendments reflect years of input to the department from EMS stakeholders and the Governor's EMS and Trauma Advisory Council (GETAC) on ways to improve the Texas EMS system.

These rules are the product of more than 15 public, statewide stakeholder meetings held 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 approved these proposed revisions and made a recommendation to GETAC to approve the proposed rules.

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

The purpose of these rule revisions is to ensure compliance with new laws and to reflect current state and national trends in the EMS industry. 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.

These rules are also in compliance with Government Code, §2001.039, which requires that each state agency review and consider for re-adoption 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 continue 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 reflect current standards.

Section 157.3, Processing EMS Provider 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 specifies the time period for the department to review applications for completeness and to process applications, in order to make eligibility determinations for various EMS certifications, licenses and approvals as required by Government Code, Chapter 2001.

Section 157.5, Rule Exemption Requests, incorporates modifications to existing rules to update language to be in alignment with current terms and practices. In addition, bureau chief references are replaced with the department and EMT-Intermediate references were removed to incorporate the use of AEMT.

Section 157.11, Requirements for Emergency Medical Services Provider Licensing, incorporates modifications to existing rules, to current standards, terms, and practices. Amendments to current rules were also added due to new legislation, 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 a city, county, or Regional Advisory Council.

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

Section 157.11(c)(7)(G) outlines the educational requirements for the AOR, to include continuing education, as required by SB 8, 83rd Legislature, Regular Session, 2013.

Section 157.11(c)(7)(J) requires that the department is provided a staffing plan that addresses coverage of a service area, to include a process of managing 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 all patient equipment to be clean, fully operational, and have a backup power source, if applicable.

Section 157.11(k)(1) - (3) explains the type of patients and level of care that is expected for 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 transmission of 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 indicating the provider is not the primary provider in that area and requires the provider to give a copy of this notice to the primary provider in the area and to the department within 30 days before it begins the subscription enrollment period.

Section 157.11(n) requires an EMS provider to have a plan established for the ongoing monitoring of the quality of patient care that is given by the EMS provider's personnel and to collect patient care data as required by 25 Texas Administrative 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, requires each EMS Provider to have an educated designated infection control officer to enhance communication between hospitals, the EMS Provider, and personnel related to an exposure event.

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, incorporates modifications to existing rules in order for language and terms to reflect current standards to include ensuring the air unit meets air worthiness statistics per federal regulations. Changes include documentation of the knowledge and experience of the medical director when treating and transporting patients by air. Also, language was removed that required bodily injury and property damage insurance coverage amounts for an aircraft provider because these amounts are established by federal regulations. In addition, rule language was included to require 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, language was amended to require a FRO License application to 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, Denial of a Provider License or Administrative Penalties, incorporates modifications to existing rule language and adds language and terms to allow the department to take disciplinary action based on an action taken by another state or federal agency. In addition, the rule language was modified to include a notification requirement for the AOR and an 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 (ECA) course, an EMT-Basic course, an Advanced EMT course and an EMT-Paramedic course. An additional amendment was included to change the name of the "Intermediate EMT-I" to "Advanced EMT" which was required by SB 219 and reflects a national name change.

Language as 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.

New rule language was added as required by U.S. Code, Title 42, Chapter 6A, subchapter XXIV, Part G, to stipulate that EMS Education Program providers must have an educated and designated infection control officer to enhance communication between the program, hospitals and students participating in the program.

Section 157.32(i)(2)(A) provides detailed information regarding the department's expectations regarding a self-study program submitted by an applicant. Throughout this section, new rule language was added to ensure medical oversight is provided during all aspects of the education program.

Section 157.32(p)(25) was added to ensure on-line or distance learning classes 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 mandated in the 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 were added for EMS personnel to:

-complete an accurate patient care record;

-report abuse or injury to a patient;

-follow the medical director's protocols and policies;

-take precautions to prevent misappropriation of medication;

-maintain skills and knowledge of level of certification; and

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

Section 157.34, Recertification, incorporates modifications to 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 oversight 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 to existing rule language and terms to reflect current standards, by requiring a continuing education program to designate an infection control officer and to verify that physician medical oversight is provided when students are involved in patient care.

Section 157.43, Course Coordinator Certification, incorporates modifications to existing rule language by increasing the teaching experience requirement for a course coordinator to four years of experience in EMS. Additionally, physician medical oversight is required when education is conducted, especially during clinic time or when advance level skills are being provided on an ambulance. Rule language was added to require more detail to be provided to students regarding what to expect from an EMS education program and the requirements necessary to become certified/licensed in Texas. Per SB 1899, rule language was added to require the education of students regarding current Texas EMS laws, rules and policies.

Section 157.43(h)(20) adds language to require a course coordinator to notify the department when leaving employment as the course coordinator for an on-going EMS education program.

Section 157.43(m)(3)(AA) adds language to explain what the department considers 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 observe or provide patient care in an ambulance, hospital or clinic for at least 8 hours every two years, in order 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 failure to notify the department if the instructor learns that a student applicant 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.

COMMENTS

The department, on behalf of the commission, held a public hearing on September 9, 2016. It was attended by 23 individuals representing the following agencies and organizations: Association of Texas EMS Professionals (ATEMSP), Allegiance Mobile Health, American Medical Response (AMR), Arlington Fire Department, Association of Texas EMS Professionals (ATEMSP), College of the Mainland, CyFair Volunteer Fire Department, HCA Healthcare, Jeff Davis County Ambulance, One Response EMS, San Angelo Fire Department, Southeast Texas Regional Advisory Council (SETRAC), Texas Department of Public Safety, Texas EMS Alliance (TEMSA), Texas EMS Trauma and Acute Care Foundation (TETAF), and Williamson County EMS. The department, on behalf of the commission, has reviewed and prepared responses to the comments received regarding the proposed rules during the public hearing, which the commission has reviewed and accepts. The department received comments from Arlington Fire Department, College of the Mainland, Jeff Davis County Ambulance, Association of Texas EMS Professionals (ATEMSP), Southeast Texas Regional Advisory Council (SETRAC), and Texas EMS Alliance (TEMSA). The commenters were not against the rules in their entirety; however, the commenters suggested recommendations for change as discussed in the summary of comments.