Part 1. TEXAS DEPARTMENT OF HEALTH

Chapter 157. EMERGENCY MEDICAL CARE

The Texas Department of Health (department) adopts the repeal of §§157.1 - 157.3, 157.11 - 157.14, 157.16 - 157.24, 157.32 - 157.35, 157.41 - 157.47, 157.51; 157.53, 157.61 - 157.64, 157.101, and 157.121 - 157.128 and new rules 157.1 - 157.3, 157.11 - 157.14, 157.16, 157.33, 157.36, 157.37, 157.43, 157.44, 157.122 - 157.123, 157.125, and 157.128 concerning emergency medical services (EMS) and trauma systems development. New sections 157.2 - 157.3, 157.11 - 157.14, 157.16, 157.33, 157.36 - 157.37, 157.43 - 157.44, 157.122 - 157.123, 157.125, and 157.128 are adopted with changes to the proposed text as published in the October 29, 1999, issue of the Texas Register (24 TexReg 9534). The repeal of §§157.1 - 157.3, 157.11 - 157.14, 157.16 - 157.24, 157.32 - 157.35, 157.41 - 157.47, 157.51, 157.53, 157.61 - 157.64, 157.101, and 157.121 - 157.128 and new §157.1 are adopted without changes and therefore will not be republished.

The repeal of §157.38, and §157.129, the amendment to §157.40, and new §§157.32, 157.34 and 157.42 which were simultaneously proposed in the October 29, 1999, issue of the Texas Register , are being withdrawn from consideration for permanent adoption.

The department adopts new rules concerning purpose; definitions; processing EMS provider licenses and applications for EMS personnel certification and licensure; requirements for an EMS provider license; rotor-wing air ambulance operations; fixed-wing air ambulance operations; requirements for first responder organization registration; emergency suspension, suspension, probation, revocation or denial of a provider license; criteria for denial and disciplinary actions for EMS personnel and voluntary surrender of a certificate or license; certification or licensure of persons with criminal backgrounds; course coordinator certification; and EMS instructor certification.

The department also adopts new rules concerning trauma service areas; regional EMS/trauma systems; requirements for trauma facility designation; and denial, suspension and revocation of trauma facility designation.

All commenters were not against the rules in their entirety, however they expressed concerns, asked questions and suggested recommendations for change as discussed in the summary of comments. Twelve commenters at the public hearing were in favor of sending the rules through the process with no changes to the text. The following comments were received during the 90-day comment period:

Comment: Concerning §157.2(9), two commenters suggested that the definition of Basic (Level IV) Trauma Facility was too narrow.

Response: The department agrees in part and has removed the word "all" from this section and from the heading section §157.125(t).

Comment: Concerning §157.2(13), three commenters suggested that the definition of Basic Trauma Facility be changed to require that an EMS provider not utilize predetermined triage criteria, but to call the physician on staff or on call at the nearest hospital before that hospital is bypassed to take a patient to another hospital.

Response: The department agrees in part and has added language that requires local physician input into the development of predetermined triage criteria and review of the criteria through the regional system performance improvement process.

Comment: Concerning §157.2(42), two commenters opposed language in the definition regarding industrial ambulances. Both suggested referencing Texas Transportation Code, Chapter 541, §201.

Response: The department agrees and has made the appropriate change.

Comment: Concerning §157.2(47), one commenter suggested that in the definition of major trauma patient, the word "designated" be removed because non-designated trauma facilities may also be capable of treating major trauma patients.

Response: The department agrees because the word "designated" is redundant in the definition - according to the enacting legislation, a hospital is not a trauma facility unless designated by the department. The wording has been corrected in this section and in §157.2(63).

Comment: Concerning §157.2(47), one commenter suggested that in the definition of "major trauma patient," the word "retrospectively" be removed because appropriateness of triage should not be based on retrospective identification.

Response: The department agrees in part and has added clarifying language to this section and §157.2(63) that the injury severity score may be used to evaluate of the appropriateness of triage retrospectively through an individual trauma care provider's and/or a regional performance improvement program.

Comment: Concerning §157.2(73), one commenter suggested that in the definition of "trauma nurse coordinator/trauma program manager" the words "the authority to positively impact care of trauma patients in all areas of the hospital" be removed because they are vague and the trauma coordinator does not need to impact care of patients once they no longer need trauma care.

Response: The department agrees in part and has changed the wording to reflect that the trauma nurse coordinator/trauma program manager should be able to positively impact trauma care of trauma patients.

Comment: Concerning §157.2(74), one commenter suggested that in the definition of "trauma patient" the words "trauma facility" be replaced by "acute care facility" because certain trauma patients may be treated in non-designated facilities.

Response: The department disagrees because the definition of "trauma patient" is directly out of the enacting legislation. No change was made as a result of this comment.

Comment: Concerning §157.11, one commenter recommends inclusion of a drug storage rule.

Response: The department disagrees because the issue is addressed by the Board of Pharmacy regulations. No change was made as a result of this comment.

Comment: Concerning §157.11(i)(1)(M), one commenter opposes the required Automatic External Defibrillators (AEDs) on Basic Life Support units.

Response: The department disagrees because of the availability of AEDs and the public access to AEDs. No change was made as a result of this comment.

Comment: Concerning §157.11(c), one commenter suggested that the language was ambivalent.

Response: The department agrees and has made the appropriate change to include the words "between providers".

Comment: Concerning §157.12(c)(6), one commenter recommended that the rule require submission of current FAA operational certification.

Response: The department agrees and has added that language.

Comment: Concerning §157.12(d), two commenters wanted clarification of the medical director credentials.

Response: The department disagrees. Several air medical providers are based in adjoining states and the language that the medical directors be "approved by the department" is sufficient. No change was made as a result of this comment.

Comment: Concerning §157.13(b), two commenters wanted clarification of the medical director credentials.

Response: The department disagrees. Several air medical providers are based in adjoining states and the language that the medical directors be "approved by the department" is sufficient. No change was made as a result of this comment.

Comment: Concerning §157.13(d)(4), one commenter recommended that the rule require submission of the provider's current Federal Aviation Air Taxi and Commercial Operator Certification.

Response: The department agrees and has added that language.

Concerning §157.14, the following comments were received from one commenter:

Comment: Concerning §157.14, one commenter recommends charging all volunteers a fee for administrative purposes.

Response: The department disagrees because fees and volunteer exemptions are mandated by statute. No change was made as a result of this comment.

Comment: Concerning §157.14, one commenter opposes the requirement that the department be advised of addition or deletion of staff except at the time of renewal of the license.

Response: The department disagrees because it is not required. No change was made as a result of this comment.

Comment: Concerning §157.14(a)(2) and (b)(5)(A), the commenter suggested that we use the word "members" which would include paid or volunteer first responder personnel instead of "employees and/or members."

Response: The department agrees with the need for a change but has changed the word to "personnel" to be consistent with the other uses of that terminology in the rule.

Comment: Concerning §157.14(b)(2), the commenter suggested that the personnel list include the Social Security number and certification level for more complete information.

Response: The department agrees and has made the change for clarity.

Comment: Concerning §157.14(b) and (b)(5)(B), the commenter suggested that "candidate" for registration should be "applicant".

Response: The department agrees and has made the change for clarity.

Comment: Concerning §157.14(c)(1), the commenter suggested that patients are "treated" not always "stabilized" by First Responder personnel.

Response: The department agrees and has changed the wording for clarity.

Comment: Concerning §157.14(c)(1), the commenter felt the agreement should be approved by the responsible person for the "First Responder Organization" not the first responder.

Response: The department agrees and has changed the wording for clarity.

Comment: Concerning 157.14(c)(2)(C), one commenter opposes the requirement for availability schedules.

Response: The department disagrees because the transporting provider should be informed of its First Responders' availability. No change was made as a result of this comment.

Comment: Concerning §157.14(d)(2), one commenter opposes the requirement for individual identification.

Response: The department disagrees because all persons rendering emergency care should be identified to the patient. No change was made as a result of this comment.

Comment: Concerning §157.14(d)(6), the commenter suggested that first responder vehicles do not always belong to the First Responder Organization, so proof of first responder registration should be carried in vehicles "used or operated" by the first responder.

Response: The department agrees and has modified the language.

Note: Due to the significant controversy surrounding the examination requirement for personnel recertification in §157.33(j), and because of the importance of the balance of the proposed rule to establishing certification criteria, including fees and other statute-mandated provisions, staff has deleted the proposed language in subsection (j) and has replaced it with language identical to that contained in the current rule subsection (j) pertaining to recertification.

Comment: Seventy three commenters oppose the reinstatement of the pass/fail requirement on the personnel recertification examination in §157.33(j).

Response: The department recognizes that conflicts between the personnel opposing the requirement and the physician medical directors who are in favor of the requirement will not be resolved in sufficient time to meet the rule submission deadline for the Board of Health meeting and has deleted the controversial section (j) and has replaced it with language identical to that contained in the current rule subsection (j) pertaining to recertification.

Comment: Thirteen commenters are in favor of the reinstatement of the pass/fail requirement on the personnel recertification examination in §157.33(j).

Response: The department recognizes that conflicts between the personnel opposing the requirement and the physician medical directors who are in favor of the requirement will not be resolved in sufficient time to meet the rule submission deadline for the Board of Health meeting and has deleted the controversial section (j).

Comment: Two commenters oppose the requirement for repeating a training course in §157.33(e)(2) following failure of a second retest.

Response: The department disagrees. Currently, only one retest attempt is allowed under the rules. The proposed rule provides for three attempts to successfully complete the credentialing examination. No change was made as a result of this comment.

Comment: Two commenters oppose the increase in late fees as proposed in §157.33(k)(2).

Response: The department disagrees. The increase in late fees is established by statute. No change was made as a result of this comment.

Comment: Two commenters oppose the elimination of the 90-day extension of certification past the expiration date.

Response: The department disagrees. The extension of certification is not a provision of the statute. No change was made as a result of this comment.

Comment: Concerning §157.123, two commenters indicated support for the rule as proposed.

Response: No change was made as a result of this comment.

Comment: Concerning §157.123, two commenters would like to see the Regional Advisory Councils (RACs) more specifically defined as to authority, responsibilities, conduct of business, voting, etc. They went on to express concern that there is no mechanism for assuring that state monies directed to and through the RACs are spent appropriately.

Response: The department disagrees because the RACs cover areas that are so diverse in geographic size, population, and numbers and levels of trauma care providers that defining a specific organizational structure that would meet the needs of all twenty-two Trauma Service Areas would be extremely difficult, which is why they have been allowed to develop a structure that meets the needs of their area. Additionally, staff do evaluate complaints regarding these issues and conduct on-site visits at RAC meetings, providing feedback to the RACs on the conduct of their business. In regards to state funding being directed to and through the RACs, the state will have a contract with each RAC for each different source of funding, which will define the appropriate uses of the funds and require specific reporting as to how all monies are spent. In addition, the RACs will be subject to audit regarding the use of state funds. No change was made as a result of these comments.

Comment: Concerning §157.123(b)(1)(E), one commenter suggested that the wording was vague and therefore not meaningful.

Response: The department agrees and has deleted and added language to clarify the meaning of the section.

Comment: Concerning §157.125, ten commenters indicated support for the rule as proposed.

Response: No change was made as a result of these comments.

Comment: Concerning §157.125, one commenter suggested that language be included that would allow hospitals to file a complaint regarding the conduct of a surveyor and a process for evaluation and resolution of those complaints.

Response: The department agrees and the language has been added as §157.125(d)(7).

Comment: Concerning §157.125(a)(1) and (a)(2), one commenter objected to adoption of the American College of Surgeons criteria regarding anesthesiology requirements for Level I and II trauma facilities because they conflict with state requirements.

Response: The department agrees, however, it is the nature of national standards that they may not always correspond exactly with every state's requirements. Additionally, each hospital may have a different process for meeting the essential criteria. That is why §157.125(k) allows the department to give an exception to criteria. No change was made as a result of this comment.

Comment: Concerning §157.125(d)(5), one commenter suggested that the words "from the department" be added because it is not appropriate for outside observers be allowed to accompany a survey team.

Response: The department agrees in part and has added the wording that a hospital may refuse to allow non-department observers to participate in a survey.

Comment: Concerning §157.125(g)(1), one commenter requested that the wording be clarified that only medical records, etc. specifically relevant to trauma care be reviewed during the survey process.

Response: The department agrees and the language has been added.

Comment: Concerning §157.125(p), one commenter stated a concern that the wording implies that non-designated facilities are inferior and requests that the wording be changed to state only that non-designated facilities cannot represent themselves as designated.

Response: The department disagrees because the wording is directly out of the enacting legislation. No change was made as a result of this comment.

Comment: Concerning §157.125(s) and (t), four commenters indicated support for the General and Basic Trauma Facility criteria as proposed.

Response: No change was made as a result of these comments.

Comment: Concerning §157.125(s), General Trauma Facility Standards and §157.125(s), criterium C(1), one commenter stated concern that there was no standard or standard audit filter related to diversion by trauma facilities.

Response: The department agrees and the language has been added as §157.125(s), General Trauma Facility Standard #4, §157.125(s), criterium C(1), Audit Filter #4, §157.125(t), Basic Trauma Facility Standard #4, and §157.125(t), criterium 4(a) Audit Filter ##4.

Comment: Concerning §157.125(s), criterium A(2)(b), one commenter pointed out that the wording "trauma coordinator" is not consistent with the wording in §157.2(73) or the national standards.

Response: The department agrees and the language has been corrected in §157.125(s), criterium A(2)(b) and §157.125(t), criterium 3(a).

Comment: Concerning §157.125(s), criterium A(2)(e), one commenter stated concern with requiring all trauma patients to be admitted to a surgeon because less than major trauma patients may not require that level of care and because the patient's primary physician may not be notified.

Response: The department agrees. The language of criterium A(2)(e) limits the requirement of admission to an appropriate surgeon to major and severe trauma patients. Additionally, criterium A(6)(b) states that it is essential that a patient's primary care physician be notified. No change was made as a result of this comment.

Comment: Concerning §157.125(s), criterium A(5)(a), one commenter pointed out that national standards require orthopedic surgery in Level III trauma facilities and the proposed criteria do not.

Response: The department agrees in part and has added the language that orthopedic surgery is required in lead facilities.

Comment: Concerning §157.125(s), criterium A(5)(a), one commenter stated that encouraging orthopedic surgeons and neurosurgeons to be credentialed the Advanced Trauma Life Support (ATLS) course is unrealistic and does not improve care.

Response: The department disagrees because the criterium is desired not essential, therefore, if the hospital does not meet it, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(s), criterium A(5)(a) and §157.125(t), criterium 2(a)(1), one commenter suggested that the term anesthesia care team be defined to assure that CRNAs are included.

Response: The department disagrees because the anesthesia care team is defined and credentialed by the hospital. No change was made as a result of this comment.

Comment: Concerning §157.125(s), criterium B(4)(b), one commenter stated that requiring a physician credentialed in critical care to be available in the hospital 24 hours per day is unrealistic for a Level III trauma facility.

Response: The department disagrees because the criterium allows for that physician to come from anywhere in the hospital, including the emergency department. No change was made as a result of this comment.

Comment: Concerning §157.125(s), criterium A(6)(a) and §157.125(t), criterium 2(a)(2)(b), one commenter supported and multiple commenters objected to the requirement for board-certified emergency physicians at Level III and Level IV trauma facilities to be credentialed in the ATLS course. Additionally, concerning §157.125(t), criterium 2(a)(2)(b), one commenter requested that the requirement for physicians covering emergency medicine at Level IV trauma facilities to be credentialed in the ATLS course be changed from essential to desired.

Response: The department agrees in part and has changed the requirement so that board- certified emergency physicians in Level III and Level IV trauma facilities do not have to meet this criterium unless they participated in the treatment of less than 10 major or severe trauma patients in the previous year and that there shall be/should be a credentialing program for emergency physicians in Level III/Level IV trauma facilities, respectively.

Comment: Concerning §157.125(t), one commenter requested assurance that all criteria currently specified as desired not be changed to essential in the future.

Response: The department agrees in that changes to the criteria can only be made through the rule process, which includes the opportunity for stakeholder input. No change was made as a result of this comment.

Comment: Concerning §157.125(t), one commenter was concerned because there is no reference to General Surgery in the Basic Trauma Facility Criteria.

Response: The department disagrees in that it would be extremely rare for most major and severe trauma patients to receive surgery at a Level IV trauma facility. Section 157.125(t) Basic Trauma Facility Standard #9 refers to the expectation that major and severe patients who are not transferred from a Level IV facility within two hours should receive the same level of care as the highest available in the Trauma Service Area. Additionally, all major and severe trauma patients who receive surgery at a Level IV trauma facility should be reviewed for quality and appropriateness of care as outlined by Basic Trauma Facility Standard Audit Filters #13 and #15. No change was made as a result of this comment.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #1, one commenter suggested changing the wording from requiring a Level IV trauma facility to participate on "its" regional system to "a" regional system because this would allow a hospital to receive permission to participate on a system that it is not assigned.

Response: The department agrees in part in that it may give approval for a hospital to participate in a different system, however, in that case it would be that hospital's system. No change was made as a result of this comment.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #5, one commenter suggested eliminating the words "severe and major" because Level IV hospitals also receive non-critical patients and the word "team" because it is not well-defined.

Response: The department disagrees because the emphasis of designation is how a hospital handles the critical/potentially critical (severe and major) trauma patients. Additionally, the hospital is required to identify its trauma team under §157.125(t), criterium 1(b). No change was made as a result of this comment.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #7, one commenter stated that the criteria for a Level IV trauma facility do not address "treatment within the capability of the facility."

Response: The department disagrees because the Basic Trauma Facility Standards are attached to the criteria document. No change was made as a result of this comment.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #8, one commenter suggested adding the wording that indicates that disposition decisions are made by a physician and transfers initiated when medically necessary.

Response: The department agrees in part and language referring to the physician's responsibility in determining transfer has been added to §157.125(t), Basic Trauma Facility Standard #8 and §157.125(s), General Trauma Facility Standard #10.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #9, one commenter suggested substituting the word inappropriately for intentionally, because there may be some situations where a patient is not transferred because of circumstances beyond the hospital's control.

Response: The department agrees and the language has been added to §157.125(t), Basic Trauma Facility Standard #9 and §157.125(s), General Trauma Facility Standard #11.

Comment: Concerning §157.125(t), Basic Trauma Facility Standard #10, one commenter suggested that the word "internally" be added, that "quality of care" be substituted for "appropriateness of care," and that "provided by the facility" be substituted for "throughout the hospital stay."

Response: The department agrees in part and has added clarifying language to §157.125(t), Basic Trauma Facility Standard #10 and §157.125(s), General Trauma Facility Standard #13.

Comment: Concerning §157.125(t), criterium 1(a)(2), two commenters requested that the wording be changed to require only one nurse with trauma training participate in initial trauma resuscitations because it is an unrealistic expectation for a rural hospital to be required to have two such nurses.

Response: The department disagrees because the criterium is desired not essential, therefore, if the hospital does not meet it, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 1(b), one commenter requested that wording be added to specify that any written protocols should be established by the facility's medical staff.

Response: The department agrees and the language has been added to §157.125(t), criterium 1(b) and to §157.125(s), criterium A(2)(d).

Comment: Concerning §157.125(t), criterium 1(c), one commenter requested that wording be added to specify that the written plan for the acquisition of additional staff as needed should be established by the facility.

Response: The department agrees and the language has been added to §157.125(t), criterium 1(c) and §157.125(s), criterium B(5)(d).

Comment: Concerning §157.125(t), criterium 1(d)(5), one commenter requested that the wording be changed to reflect the ability to establish a central venous line rather that the piece of equipment.

Response: The department disagrees because the criteria 1(d) are a list of equipment, not procedures. Additionally, the criterium 1(d)(5) is desired not essential, therefore, if the hospital does not meet it, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criteria 1(e)(1)(b) and 1(e)(1)(c), one commenter requested that the requirements for 24 hour coverage by an in-house radiological technician and computerized tomography be removed because they are unrealistic expectations for a rural hospital.

Response: The department disagrees because the criteria are desired not essential, therefore, if the hospital does not meet them, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 2(a)(4), one commenter requested clarification on what Radiology Physician requirements need to be available.

Response: The department responds that this is up to the hospital and that this criterium is desired not essential, therefore, if the hospital does not meet it, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criteria 3(e) and (f), one commenter requested re- numbering the criteria to move 3(f) to 3(e)(3) and commented that expecting rural hospitals to have 50% of nurses caring for trauma patients to be certified in their area of specialty is unrealistic.

Response: The department disagrees because 3(e) and 3(f) relate to different educational requirements and because the criterium 3(f) is desired not essential, therefore, if the hospital does not meet it, there are no consequences. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 4(a), one commenter requested that the wording be clarified that the performance improvement program is developed by the hospital. Response: The department agrees and the clarifying language has been added to §157.125(t), criterium 4(a) and §157.125(s), criterium C(1).

Comment: Concerning §157.125(t), criterium 4(a), one commenter questions the inclusion of audit filters regarding admission to the hospital without evaluation by a physician, admission of patients to surgery or the ICU, and transfers to a non-designated facility because they may be medically appropriate.

Response: The department agrees that such actions by a level IV may be medically appropriate, but contends that it is the trauma performance improvement process that makes this determination. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 4(a)(2), one commenter requested that the wording be changed from requiring the hospital to audit trauma charts for "appropriateness of care" to "quality of care."

Response: The department agrees in part and has changed the wording to include quality of care in §157.125(t), criterium 4(a)(2) and §157.125(s), criterium C(5).

Comment: Concerning §157.125(t), criterium 5, one commenter would like the wording requiring trauma facilities to meet RAC requirements for participation to be removed.

Response: The department disagrees because each RAC has defined their participation requirements per the needs of the regional system. Additionally, development of a comprehensive regional system is dependent on participation by all trauma care providers. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 7, two commenters would like the requirement for a Level IV trauma facility to have a program to address the major injury problems with the hospital's service area to be changed from essential to desired.

Response: The department disagrees because prevention programs by individual trauma care providers are a critical element of a trauma system. Additionally, the criterium may be met by participating in a RAC's program. No change was made as a result of this comment.

Comment: Concerning §157.125(t), criterium 8, one commenter objects to requiring a Level IV trauma facility to pay for physicians' continuing education.

Response: The department disagrees that the wording is requiring the hospital to pay for the physicians' continuing education, only to make it available. No change was made as a result of this comment.

No comments were received on the following subsections, but the changes were made by staff to clarify the intent and accuracy of the sections.

Change: Concerning §157.37, in subsections (a), (b)(3), (c)(2)(A), and (d), the department has changed the citations of "Texas Civil Statutes, Article 6252" to "Occupations Code, Chapter 53" due to recodification of the statutes. Other minor changes were made to clarify the intent and improve the accuracy of the wording regarding investigations of criminal history of EMS personnel.

Change: Concerning §157.3(b)(1) and (2), the wording was changed because it was redundant.

Change: Concerning §157.11(l)(4), the wording was changed to reflect withdrawal of §157.34 from adoption.

Change: Concerning §157.16(e)(4), (5), and (6), the numbering was corrected from the incorrect numbering in the proposed rule.

Change: Concerning §157.36(b)(21), language was changed to broaden the scope of reporting obligations.

Change: Concerning §157.44(b)(4), language was included to exempt volunteer instructors from fees.

Change: Concerning §157.37(c)(3)(G), this new paragraph has been added to strengthen the list of offenses which may be considered and reviewed in relation to certification and licensure of EMS personnel.

Change: Concerning 157.37(d), wording was changed to clarify the department position on conduct of EMS personnel with regard to criminal history evaluation.

Change: Concerning §157.43(d)(1), the wording was changed to allow exemption of a fee for volunteers if they receive no compensation for coordinating courses or programs.

Change: Concerning §157.43(d)(8), the wording was changed for clarification. A one- year limit was added, retesting was allowed and a retest fee was specified. Requirements for certification were specified if the requirements were not completed within the one-year period after course completion.

Change: Concerning §157.43(e)(1), wording was added to allow an exemption of a fee for volunteers if they receive no compensation for coordinating training courses.

Change: Concerning §157.43(e)(9), wording was edited for clarity and a one-year limit was added. Allowance for a retest and a retest fee was added was added. If the requirements for certification are not completed within one year, the new requirements are added to the section.

Change: Concerning §157.43(e)(10), the wording for the requirements for a basic coordinator applying for advanced coordinator certification has been added for clarity.

Change: Concerning §157.43(j)(3), clarifying language has been added to the paragraph to prevent stacking of certification periods.

Change: Concerning §157.43(l), reference to the late fee and reference to §157.33 were eliminated.

Change: Concerning §157.43(l), the paragraph was reordered and clarifying language for late recertification has been added.

Change: Concerning §157.44(f)(3), wording has been added to clarify the requirements and to prevent stacking of certification periods.

Change: Concerning §157.44(h), new paragraph (h) has been added from paragraph (g) to clarify the requirements for recertification.

Change: Concerning §157.122, since proposal of the rule Tyler county has re-aligned from Trauma Service Area-R to Trauma Service Area-H. The language has been corrected in (c)(8) and (c)(18).

Change: Concerning §157.125, performance improvement is the current verbiage for quality management or improvement activities, therefore the language has been corrected in (g) (1), (r), (t)criterium 1(e)(2)(e), (t)criterium 2(a)(2)(c), (t)criterium 4, (t)criterium 4(a), (t) criterium 4(a)(4), and (t)criterium 8.

Change: Concerning §157.125(r), the citation regarding Open Records was changed after recodification of the statute.

Change: Concerning §157.128(a)(11), the citation regarding Occupation Code was changed after recodification of the statute.

Change: Concerning §157.128(c)(1), the word postmark was removed for consistency.

The commenters were the Texas Heart Association, Heart of Texas Regional Advisory Council, Texas Ambulance Association, Texas Association of Nurse Anesthetists, Texas College of Emergency Physicians, Texas Organization of Rural and Community Hospitals, Texas Trauma Coordinators Forum, Arlington Memorial Hospital, Baylor College of Medicine, Ben Taub General Hospital, Christus St. Joseph Hospital, Los Colinas Medical Center, Memorial Health System, Memorial Hermann Southeast Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann The Woodlands Hospital, Methodist Healthcare System, North Hills Hospital, Permian General Hospital, Questcare, Republic Emergency Services, Richards Memorial Hospital, Sabine County Hospital, St. Joseph Regional Health Center, Southwest Texas Emergency Physicians Management Service Association, Team Health Southwest, Texas Tech University Health Sciences Center at El Paso, Texoma Medical Center, Third Coast Emergency Physicians, United Regional Health Care System, University of North Texas Health Science Center at Fort Worth, University of Texas Health Science Center at San Antonio, University of Texas Southwestern Medical Center at Dallas, and department staff. In addition, numerous individuals commented. All commenters were not for or against the rules in their entirety, however they expressed affirmatory comments, concerns, asked questions, and/or suggested recommendations for change as discussed in the summary of comments.

Subchapter A. EMERGENCY MEDICAL SERVICES - PART A

25 TAC §§157.1 - 157.3

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002566

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.1 - 157.3

The new rules are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

§157.2.Definitions.

The following words and terms, when used in these sections, shall have the following meanings, unless the context clearly indicates otherwise:

(1)

Abandonment - Leaving a patient without medical care once patient contact has been established, unless emergency medical services personnel are following a physician directive or the patient signs a release; turning the care of a patient over to an individual of lesser training when advanced treatment modalities have been initiated to include, but not limited to, IVs, intubation, and drug therapy.

(2)

Accreditation - Formal recognition by a national association of a provider's service or an education program based on voluntarily met standards established by that association.

(3)

Act - Emergency Medical Services Act, Health and Safety Code, Chapter 773.

(4)

Advanced life support (ALS) - Emergency prehospital or interfacility care that uses invasive medical acts. The provision of advanced life support shall be under the medical supervision and control of a licensed physician.

(5)

Advanced life support (ALS) vehicle - A vehicle that is designed for transporting the sick and injured and that meets the requirements of a basic life support vehicle and has sufficient equipment and supplies for providing intravenous therapy and endotracheal or esophageal intubation or both.

(6)

Air ambulance provider - A person who operates/leases a fixed-wing or rotor-wing air ambulance aircraft, equipped and staffed to provide a medical care environment on-board appropriate to the patient's needs. The term air ambulance provider is not synonymous with and does not refer to the Federal Aviation Administration (FAA) air carrier certificate holder unless they also maintain and control the medical aspects that are consistent with EMS provider licensure.

(7)

Basic life support (BLS) - Emergency prehospital or interfacility care that uses noninvasive medical acts. The provision of basic life support shall be under the medical supervision and control of a licensed physician.

(8)

Basic life support (BLS) vehicle - A vehicle that is designed for transporting the sick or injured and that has sufficient equipment and supplies for providing basic life support.

(9)

Basic trauma facility - A hospital designated by the department as having met the criteria for a Level IV trauma facility as described in §157.125 of this title (relating to Requirements for Trauma Facility Designation). Basic trauma facilities provide resuscitation, stabilization, and arrange for appropriate transfer of major and severe trauma patients to a higher level trauma facility, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.

(10)

Board - The Texas Board of Health.

(11)

Bureau - The Bureau of Emergency Management of the Texas Department of Health.

(12)

Bureau chief - The chief of the Bureau of Emergency Management.

(13)

Bypass - Direction given to a prehospital emergency medical services unit, by direct/on-line medical control or predetermined triage criteria, to pass the nearest hospital for the most appropriate hospital/trauma facility. Bypass protocols should have local physician input into their development and should be reviewed through the regional performance improvement process.

(14)

Candidate - An individual who is requesting emergency medical services personnel certification or licensure, recertification or relicensure from the Texas Department of Health.

(15)

Certificant - Emergency medical services personnel with current certification from the Texas Department of Health.

(16)

Comprehensive trauma facility - A hospital designated by the department as having met the criteria for a Level I trauma facility as described in §157.125 of this title. Comprehensive trauma facilities manage major and severe trauma patients, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, implement targeted injury prevention programs, and conduct trauma research.

(17)

Course medical director - A licensed physician approved by the department with experience in and current knowledge of emergency care who shall provide direction over all instruction and clinical practice required in EMS training courses.

(18)

Credit hour - Continuing education credit unit awarded for successful completion of a unit of learning activity as defined in §157.32 of this title (relating to EMS Education Program and Course Approval).

(19)

Critically injured person - A person suffering major or severe trauma, with severe multi system injuries or major unisystem injury; the extent of the injury may be difficult to ascertain, but which has the potential of producing mortality or major disability.

(20)

Department - The Texas Department of Health.

(21)

Designation - A formal recognition by the department of a hospital's trauma care capabilities and commitment.

(22)

Diversion - A procedure put into effect by a trauma facility to insure appropriate patient care when that facility is unable to provide the level of care demanded by a trauma patient's injuries or when the facility has temporarily exhausted its resources.

(23)

Emergency call - a telephone call or other similar communication from a member of the public, as part of a 9-1-1 system or other emergency access communication system, made to obtain emergency medical services.

(24)

Emergency care attendant (ECA) - An individual who is certified by the department as minimally proficient to provide emergency prehospital care by providing initial aid that promotes comfort and avoids aggravation of an injury or illness.

(25)

Emergency medical services (EMS) - Services used to respond to an individual's perceived need for immediate medical care and to prevent death or aggravation of physiological or psychological illness or injury.

(26)

Emergency medical services (EMS) operator - a person who, as an employee of a public agency, as that term is defined by Health and Safety Code, §771.001, receives emergency calls.

(27)

Emergency Medical Service Administrator - The principal executive manager of an emergency medical service organization who is responsible for the non-medical operations, staffing, policies and procedures, and overall management of the service.

(28)

Emergency medical services and trauma care system - An arrangement of available resources that are coordinated for the effective delivery of emergency health care services in geographical regions consistent with planning and management standards.

(29)

Emergency medical services personnel -

(A)

emergency care attendant (ECA);

(B)

emergency medical technician (EMT);

(C)

emergency medical technician-intermediate (EMT-I); or

(D)

emergency medical technician-paramedic (EMT-P).

(30)

Emergency medical services (EMS) provider - A person who uses, operates or maintains EMS vehicles and EMS personnel to provide EMS. See §157.11 of this title (relating to Requirements for an EMS Provider License) regarding fee exemption.

(31)

Emergency medical services (EMS) volunteer provider - An EMS which has at least 75% of the total personnel as volunteers and is a nonprofit organization. See §157.11 of this title regarding fee exemption.

(32)

Emergency medical services (EMS) volunteer - EMS personnel who provide emergency prehospital or interfacility care in affiliation with a licensed EMS provider or a registered First Responder organization without remuneration, except for reimbursement for expenses.

(33)

Emergency medical technician (EMT) - An individual who is certified by the department as minimally proficient to perform emergency prehospital care that is necessary for basic life support and that includes the control of hemorrhaging and cardiopulmonary resuscitation.

(34)

Emergency medical technician-intermediate (EMT-I) - An individual who is certified by the department as minimally proficient in performing skills required to provide emergency prehospital or interfacility care by initiating and maintaining under medical supervision certain procedures, including intravenous therapy and endotracheal or esophageal intubation or both.

(35)

Emergency medical technician-paramedic (EMT-P) - An individual who is certified by the department as minimally proficient to provide emergency prehospital or interfacility care by providing advanced life support that includes initiation and maintenance under medical supervision of certain procedures, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.

(36)

Emergency medical services vehicle-

(A)

basic life support vehicle;

(B)

advanced life support vehicle;

(C)

mobile intensive care unit (MICU);

(D)

MICU rotor wing and MICU fixed wing air medical vehicles; or

(E)

specialized emergency medical service vehicle.

(37)

Emergency prehospital care - Care provided to the sick and injured before or during transportation to a medical facility, including any necessary stabilization of the sick or injured in connection with that transportation.

(38)

Facility triage - The process of assigning patients to an appropriate trauma facility based on injury severity and facility availability.

(39)

General trauma facility - A hospital designated by the department as having met the criteria for a Level III trauma facility as described in §157.125 of this title. General trauma facilities provide resuscitation, stabilization, and assessment of injury victims and either provide treatment or arrange for appropriate transfer to a higher level trauma facility, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.

(40)

Governmental entity - A county, a city or town, a school district, or a special district or authority created in accordance with the Texas Constitution, including a rural fire prevention district, an emergency services district, a water district, a municipal utility district, and a hospital district.

(41)

Health care entity - A first responder, EMS provider, physician, nurse, hospital, designated trauma facility, or a rehabilitation program.

(42)

Industrial ambulance - Any vehicle owned and operated by an industrial facility as defined in the Texas Transportation Code, Chapter 541, §201, and used for initial transport or transfer of company employees who become urgently ill or injured on company premises to an appropriate medical facility.

(43)

Interfacility care - Care provided while transporting a patient between medical facilities.

(44)

Lead trauma facility - A trauma facility that has made an additional commitment to its trauma service area. This commitment, which usually is offered by the highest level of trauma facility in a given trauma service area, includes receipt of major and severe trauma patients transferred from lower level trauma facilities. It also includes on-going support of the regional advisory council and the provision of regional outreach, prevention, and trauma educational activities to all trauma care providers in the trauma service area regardless of health care system affiliation.

(45)

Licensee - An individual who holds a current paramedic license from the Texas Department of Health (department); an individual who uses, maintains or operates EMS vehicles and EMS personnel to provide EMS and who holds an EMS provider license from the department.

(46)

Major trauma facility - A hospital designated by the department as having met the criteria for a Level II trauma facility as described in §157.125 of this title. Major trauma facilities provide similar services to the Level I trauma facility although research and some medical specialty areas are not required for Level II facilities, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.

(47)

Major trauma patient - A person with injuries, or potential injuries, severe enough to benefit from treatment at a trauma facility. These patients may or may not present with alterations in vital signs or level of consciousness or obvious significant injuries (see severe trauma patient), but have been involved in an incident which results in a high index of suspicion for significant injury and/or disability. Co-morbid factors such as age and/or the presence of significant medical problems should also be considered. These patients should initiate a system's or health care entity's trauma response, including prehospital triage to a designated trauma facility. For performance improvement purposes, these patients are also identified retrospectively by an injury severity score of 9 or above.

(48)

Medical control - The supervision of prehospital emergency medical service providers by a licensed physician. This encompasses on-line (direct voice contact) and off-line (written protocol and procedural review).

(49)

Medical Director - The licensed physician who provides medical supervision to the EMS personnel of a licensed EMS provider under the terms of the Medical Practices Act (Chapter 6, Texas Civil Statutes 4495b) and rules promulgated by the Texas State Board of Medical Examiners. Also may be referred to as off-line medical control.

(50)

Medical oversight - The assistance and management given to health care providers and/or entities involved in regional EMS/trauma systems planning by a physician or group of physicians designated to provide technical assistance.

(51)

Medical supervision - Direction given to emergency medical services personnel by a licensed physician under the terms of the Medical Practice Act, (Texas Civil Statutes, Chapter 6, Article 4495b) and rules promulgated by the Texas State Board of Medical Examiners pursuant to the terms of the Medical Practice Act.

(52)

Mobile intensive care unit (MICU) - a vehicle that is designed for transporting the sick or injured and that meets the requirements of the advanced life support vehicle and has sufficient equipment and supplies to provide cardiac monitoring, defibrillation, cardioversion, drug therapy, and two-way communication.

(53)

Operational policies - Policies and procedures which are the basis for the operation of EMS include, but are not limited to such areas as vehicle maintenance, proper maintenance and storage of supplies, equipment, medications, and patient care devices; complaint investigation, multicasualty incidents, hazardous materials; but do not include personnel or financial policies.

(54)

Person - An individual, corporation, organization, government, governmental subdivision or agency, business, trust, partnership, association, or any other legal entity.

(55)

Prehospital triage - The process of identifying medical/injury acuity or the potential for severe injury based upon physiological criteria, injury patterns, and/or high-energy mechanisms and transporting patients to a facility appropriate for their medical/injury needs. Prehospital triage for injury victims is guided by the prehospital triage protocol adopted by the regional advisory council (RAC) and approved by the department.

(56)

Quality management - Quality assurance, quality improvement, and/or performance improvement activities.

(57)

Regional EMS/trauma system - An EMS and trauma care system that has been developed by a RAC in a multi-county area and has been recognized by the department. The Texas Trauma system is a network of the regional EMS/trauma systems.

(58)

Regional medical control - Physician supervision for prehospital emergency medical services (EMS) providers in a given trauma service area or other geographic area intended to provide standardized oversight, treatment, and transport guidelines, which should, at minimum, follow the regional advisory council's regional EMS/trauma system plan components related to these issues.

(59)

Recertification - The procedure for renewal of emergency medical services certification.

(60)

Reciprocity - The recognition of certification or privileges granted to an individual from another state.

(61)

Relicensure - The procedure for renewal of a paramedic license as described in §157.40 of this title (relating to Paramedic Licensure); the procedure for renewal of an EMS provider license as described in §157.11 of this title.

(62)

Response ready - When an EMS vehicle is equipped and staffed in accordance with §157.11 of this title (relating to Requirements for a Provider License) and is immediately available to respond to any emergency call.

(63)

Severe trauma patient - A person with injuries or potential injuries that require treatment at a tertiary trauma facility. These patients may be identified by an alteration in vital signs and/or level of consciousness or by the presence of significant injuries and shall initiate a system's and/or health care entity's highest level of trauma response including prehospital triage to a designated trauma facility. For performance improvement purposes, these patients are also identified retrospectively by an injury severity score of 15 or above.

(64)

Shall - Mandatory requirements.

(65)

Site survey - An on-site review of a trauma facility applicant to determine if it meets the criteria for a particular level of designation.

(66)

Sole provider - The only licensed emergency medical service provider in a geographically contiguous service area and in which the next closest provider is greater than 20 miles from the limits of the area.

(67)

Specialized emergency medical services vehicle - A vehicle that is designed for responding to and transporting sick or injured persons by any means of transportation other than by standard automotive ground ambulance or rotor or fixed wing air craft and that has sufficient staffing, equipment and supplies to provide for the specialized needs of the patient transported. This category includes, but is not limited to, water craft, off-road vehicles, and specially designed, configured or equipped vehicles used for transporting special care patients such as critical neonatal or burn patients.

(68)

Specialty centers - Entities that care for specific types of trauma patients such as pediatric hospitals and burn units that have received certification, categorization, verification or other form of recognition by an appropriate agency regarding their capability to definitively treat these types of patients.

(69)

Staffing plan - A document which indicates the overall working schedule patterns of EMS personnel.

(70)

Standard of care - Care equivalent to what any reasonable, prudent person of like certification level would have given in a similar situation, based on local or regionally adopted standard emergency medical services curricula as adopted by reference in §157.32 of this title (relating to Emergency Medical Services Training and Course Approval).

(71)

Trauma - An injury or wound to a living body caused by the application of an external force or violence, including burn injuries. Poisonings, near-drownings and suffocations, other than those due to external forces are to be excluded from this definition.

(72)

Trauma facility - A hospital that has successfully completed the designation process, is capable of stabilization and/or definitive treatment of critically injured persons and actively participates in a regional EMS/trauma system.

(73)

Trauma nurse coordinator/trauma program manager - A registered nurse with demonstrated interest, education, and experience in trauma care and who, in partnership with the trauma medical director and hospital administration, is responsible for coordination of trauma care at a designated trauma facility. This coordination should include active participation in the trauma performance improvement program, the authority to positively impact trauma care of trauma patients in all areas of the hospital, and targeted prevention and education activities for the public and health care professionals.

(74)

Trauma patient - Any critically injured person who has been evaluated by a physician, a registered nurse, or emergency medical services personnel, and found to require medical care in a trauma facility.

(75)

Trauma registry - A statewide database which documents and integrates medical and system information related to the provision of trauma care by health care entities.

(76)

When in service - The period of time when an EMS vehicle is at the scene or when en route to a facility with a patient.

§157.3.Processing EMS Provider Licenses and Applications for EMS Personnel Certification and Licensure.

(a)

Purpose. The purpose of this section is to set out the time periods by which the Texas Department of Health (department) processes applications for emergency medical services (EMS) provider licenses and EMS personnel certification and licensure.

(b)

First time period. The first period is a time from the date of receipt of an application to the date of issuance of a written notice that the application is complete or that additional specific information is required. An appointment for the survey of an EMS provider may be in lieu of the notice of acceptance of a complete application. The time periods for each application are as follows.

(1)

EMS provider licenses. The time periods are 21 days for the letter of deficiency and 45 days after completing licensure requirements for the issuance of the EMS provider license.

(2)

EMS personnel certificates or licenses. The time periods are 21 days for the letter of deficiency and 45 days after testing for the issuance of EMS personnel certificate or license.

(c)

Second time period. The second period is a time from the date of receipt of the last item necessary to complete the application, including survey or testing, to the date of issuance of written notice approving or denying the application. The denial time periods include notification of the proposed decision and the opportunity for an informal or formal hearing. The time periods for each application are as follows.

(1)

EMS provider license.

(A)

The time period for the initial letter of approval for a license is 45 days.

(B)

The time period for the letter of denial for a license is 120 days. The time period includes the applicant requests for a variance from minimum standards and the review necessary for this request.

(C)

The time period for the issuance of a license is 45 days.

(2)

EMS personnel certificates or licenses.

(A)

The time period for the letter of approval for an examination is 45 days.

(B)

The time period for the letter of denial for an examination is 180 days. This time limit reflects the applicant being investigated for acceptance for examination based on a criminal conviction or statutory action under the Health and Safety Code, Chapter 773 and rules adopted thereunder.

(C)

The time period for the issuance of a certificate or license is 45 days.

(d)

Reimbursement of fees.

(1)

In the event the application is not processed in the time periods as stated in subsections (b) and (c) of this section, the applicant has the right to request of the bureau chief of the Bureau of Emergency Management, full reimbursement of all filing fees paid in that particular application process. If the bureau chief does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request will be denied.

(2)

Good cause for exceeding the period established is considered to exist if:

(A)

the number of applications for licenses, registrations, certifications, and permits as appropriate to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;

(B)

another public or private entity utilized in the application process caused the delay; or

(C)

other conditions existed giving good cause for exceeding the established periods.

(e)

Appeal. If the request for full reimbursement authorized by subsection (d) of this section is denied, the applicant may then appeal to the commissioner of health for a resolution of the dispute. The applicant shall give written notice to the commissioner that he requests full reimbursement of all filing fees paid because his application was not processed within the adopted time period. The bureau chief shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The commissioner will make the final decision and provide written notification of his decision to the applicant and the bureau chief.

(f)

Contested case hearing. If at any time during the processing of the application during the second time period, a contested case hearing becomes involved, the time periods in §1.34 of this title (relating to Time Periods for Conducting Contested Case Hearing) are applicable.

(g)

Application for EMS provider license by a corporation. An applicant for an EMS provider license who is a corporation under the Texas Business Corporation Act, Texas Civil Statutes, Article 2.45, shall provide the department with an affidavit issued by the comptroller's office attesting to the applicant's good standing under the Tax Code, Texas Codes Annotated, Chapter 171; and shall comply with department requirements regarding payment of franchise taxes by corporations contracting with the department or applying for a license from the department as described in §1.161 of this title (relating to Delinquent Corporate Franchise Taxes).

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002567

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.11 - 157.14, 157.16 - 157.24

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002568

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.11 - 157.14, 157.16

The new rules are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

§157.11.Requirements for an EMS Provider License.

(a)

Application requirements for an Emergency Medical Services (EMS) Provider License.

(1)

Candidates for an EMS provider license shall submit a completed application (application, all other required information described in a provider licensing instruction document provided by the Texas Department of Health (department) and a nonrefundable an fee) to the department.

(2)

The nonrefundable fee shall be $150 for each EMS vehicle to be operated unless the license is issued for less than 12 months in which case the nonrefundable fee shall be $75 for each vehicle.

(3)

If an air ambulance provider advertises in Texas and operates an air ambulance service, the provider shall be required to have a Texas EMS Provider License.

(4)

A rotor-wing air ambulance provider from New Mexico, Oklahoma, Arkansas, or Louisiana may apply for reciprocal issuance of a provider license. A nonrefundable administrative fee of $250 shall accompany the application in addition to the nonrefundable fee in subsection (a)(2) of this section.

(5)

Applicants who have no more than five full-time paid medical and support staff, or the full-time equivalent, and who operate with at least 75% volunteer personnel, are exempt from the payment of fees.

(b)

Licenses and Designations. Candidates who meet all the criteria for licensure shall be issued a provider license. Licenses may be issued for less than two years for administrative purposes. Licensed EMS providers (providers) shall comply with all requirements of their license at all times.

(1)

Licenses. Providers shall be issued a license for a specific number of vehicles. Copies of the license shall be prominently displayed in a public area of the provider's headquarters and in the patient compartment of each of the provider's vehicles.

(2)

Designations. The provider will indicate to the department the number of vehicles designated at each level. Designations are not required to be dedicated to a particular vehicle. A designation at one of the following levels shall be prominently displayed in the patient compartment of each vehicle:

(A)

Basic Life Support (BLS);

(B)

BLS with Advanced Life Support (ALS) capability;

(C)

BLS with Mobile Intensive Care Unit (MICU) capability;

(D)

ALS;

(E)

ALS with MICU capability;

(F)

MICU;

(G)

MICU Air:

(i)

Rotor wing; or

(ii)

Fixed wing; and

(H)

specialized.

(c)

Transfer of licenses and designations. Licenses and designations are not transferable between providers.

(d)

Vehicles.

(1)

All EMS vehicles must be adequately constructed, equipped, maintained and operated to render patient care, comfort and transportation safely and efficiently. EMS vehicles must allow the proper and safe storage and use of all required equipment, supplies and medications and must allow all required procedures to be carried out in a safe and effective manner. Unless otherwise approved by the department, ground vehicles must conform to one of the body types generally recognized as Type I, II, or III.

(2)

When response-ready or in-service, EMS vehicles shall have operational two- way communication capable of contacting appropriate medical resources, and shall be in compliance with all applicable state and/or federal laws and; except for fixed wing aircraft shall have the name of the provider prominently displayed on both sides of the vehicle. Licensed providers who operate rotor or fixed wing aircraft must comply with all requirements of §157.12 of this title (relating to Rotor- wing Air Ambulance Operations) or §157.13 of this title (relating to Fixed-wing Air Ambulance Operations).

(3)

Substitution, replacement and additional vehicles.

(A)

If a provider substitutes or replaces a vehicle, there is no fee, but the department shall be notified within 10 days.

(B)

If a provider adds a vehicle to the fleet, a nonrefundable fee is required and the department shall be notified within 10 days of the designation assigned to the vehicle.

(e)

Required Minimum Staffing.

(1)

BLS - when response-ready or in-service - two emergency care attendants (ECA)'s.

(2)

BLS with ALS capability - when response-ready or in-service below ALS - two ECA's. Full ALS status becomes active when staffed by at least an emergency medical technician (EMT)-Intermediate and at least an EMT.

(3)

BLS with MICU capability - when response-ready or in-service below MICU- two ECA's. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.

(4)

ALS - when response-ready or in-service - one EMT-Intermediate and one EMT.

(5)

ALS with MICU capability - when response-ready or in-service below MICU- one EMT-Intermediate and one EMT. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.

(6)

MICU - when response-ready or in-service - one certified or licensed paramedic and one EMT.

(7)

Specialized - when response-ready or in-service - two certified or licensed personnel, certification or licensure level determined by the type and application of the vehicle and approved by the medical director.

(8)

For air ambulance staffing requirements refer to §157.12(f) of this title or §157.13(g) of this title.

(9)

As justified by patient needs, providers may utilize appropriately certified and/or licensed medical personnel in addition to those which are required by their designation levels. In addition to the care rendered by the required staff, the provider shall be accountable for care rendered by any additional personnel.

(f)

Protocols. The provider shall submit protocols approved by the provider's medical director identifying procedures for each EMS certification or license level utilized by the provider. Protocols shall also address the use of non-EMS certified or licensed medical personnel who, in addition to the EMS staff provide patient care on behalf of the provider and/or in the provider's EMS vehicles. Physicians, nurses, and other health care practitioners who regularly provide patient care in EMS vehicles shall be EMS certified. The protocols shall address the use of all required, additional, and specialized medical equipment carried by any EMS vehicle in the provider's fleet. Protocols shall have an effective date and an expiration date which corresponds to the effective and expiration dates of the provider's EMS license, and shall indicate specific applications including geographical area and duty status of personnel. For patient care reasons and with appropriate consideration from the medical director, a provider's protocols may be expanded or overridden by on-line medical control, off-line medical direction or by patient-specific orders.

(g)

Equipment and supplies. The provider shall submit an equipment and supply list which is approved by the medical director and which is consistent with, and fully supportive of, the protocols. The list shall specify an adequate variety of sizes and types and shall specify quantities appropriate to the provider's call volume, transport times and restocking capabilities. All equipment and supplies shall be clean and in working order. During unannounced inspections consideration will be given to equipment and supply deficiencies caused by recent or repeated EMS calls.

(h)

The requirements for air ambulance equipment and supplies are listed in §157.12 (h) of this title or §157.13 (h) of this title.

(i)

At least the following equipment and supplies shall be present on each in-service vehicle and on, or immediately available for, each response-ready vehicle at all times:

(1)

BLS:

(A)

oropharyngeal airways;

(B)

portable and vehicle mounted suction;

(C)

bag valve mask units, oxygen capable;

(D)

portable and vehicle mounted oxygen;

(E)

oxygen delivery devices;

(F)

dressing and bandaging materials;

(G)

rigid cervical immobilization devices;

(H)

spinal immobilization devices;

(I)

extremity splints;

(J)

equipment to meet special patient needs;

(K)

equipment for determining and monitoring patient vital signs, condition or response to treatment;

(L)

medications as required by protocols;

(M)

Automatic External Defibrillator (AED) or equivalent; and

(N)

patient transport device capable of being secured to the vehicle.

(2)

ALS or BLS with ALS capability:

(A)

all required BLS equipment;

(B)

advanced airway equipment; and

(C)

IV equipment and supplies.

(3)

MICU, BLS with MICU capability, ALS with MICU capability:

(A)

all required BLS and ALS equipment; and

(B)

cardiac monitor/defibrillator (in lieu of AED).

(4)

In addition to medical supplies and equipment:

(A)

protocols approved by the current medical director;

(B)

emergency warning devices;

(C)

personal protective equipment for the crew to include at least:

(i)

protective, non-porous gloves;

(ii)

medical eye protection;

(iii)

medical respiratory protection;

(iv)

medical protective gowns or equivalent; and

(v)

personal cleansing supplies;

(D)

sharps container;

(E)

biohazard bags;

(F)

fire extinguisher; and

(G)

no smoking signs.

(5)

As justified by specific patient needs, and when qualified personnel are available, providers may appropriately utilize equipment in addition to that which is required by their designation levels. Equipment used must be consistent with protocols and/or patient-specific orders and must correspond to personnel qualifications.

(j)

National accreditation. If a provider has been accredited through a national accrediting organization approved by the department and adheres to Texas staffing level requirements, the department may exempt the provider from portions of the license process. In addition to other licensing requirements, accredited providers shall submit:

(1)

an accreditation self-study;

(2)

a copy of formal accreditation certificate; and

(3)

any correspondence or updates to or from the accrediting organization which impact the provider's status.

(k)

Subscription or Membership Services. An EMS provider who operates or intends to operate a subscription or membership program for the provision of EMS within the provider service area shall meet all the requirements for an EMS provider license as established by the Health and Safety Code, Chapter 773, and the rules adopted thereunder, and shall obtain department approval prior to soliciting, advertising or collecting subscription or membership fees. In order to obtain department approval for a subscription or membership program, the EMS provider shall:

(1)

have a written authorization from the bureau chief elected official of the governmental entity for the provision of subscription emergency prehospital care within that governmental service area;

(2)

submit a sample of the contract for subscription service, membership and/or the application used to enroll participants;

(3)

submit a copy of all advertising used to promote the subscription service at the time of application for each license period. The EMS provider shall maintain a current file of all advertising for the service;

(4)

comply with all state and federal regulations regarding billing and reimbursement for participants in the subscription service;

(5)

provide evidence of financial responsibility by:

(A)

obtaining a surety bond payable to the department in an amount equal to the funds to be subscribed. The surety bond must be issued by a company licensed by or eligible to do business in the State of Texas; or

(B)

submitting satisfactory evidence of self insurance if the provider is a function of a governmental entity;

(6)

not deny EMS to nonsubscribers or subscribers of noncurrent status;.

(7)

be reviewed at least every two years when the provider license is renewed; and the subscription program may be reviewed by the department during spot inspections;

(8)

furnish the names and addresses of all subscribers/members to the department at the beginning of each licensure period in a format mutually acceptable to both the department and the provider; and

(9)

not offer membership nor accept members into the program who are Medicaid clients.

(l)

Responsibilities of the EMS provider. During the license period the provider's responsibilities shall include:

(1)

assuring that all response-ready and in-service vehicles are maintained, operated, equipped and staffed in accordance with the requirements of the provider's license;

(2)

monitoring and taking appropriate action regarding the quality of patient care provided by the service;

(3)

monitoring and taking appropriate action regarding the performance of all personnel involved in the provision of EMS; and ensuring that all personnel are properly certified or licensed;

(4)

assuring that continuing education (CE) training is current in accordance with the requirements in §157.38 of this title (regarding Continuing Education);

(5)

assuring that all personnel, when on an in-service vehicle or when on-scene, are prominently identified by name, certification or license level and provider name

(6)

maintaining confidentiality of patient information;

(7)

assuring that all relevant patient care information is supplied to receiving facilities upon delivery of patients;

(8)

assuring that all requested patient records are made promptly available to the medical director;

(9)

making available on each vehicle current protocols, current equipment and supply lists, a copy of the provider license and the correct designation;

(10)

monitoring and enforcing general safety policies including at least personal protective equipment, immunizations and communicable disease exposure and emergency vehicle operation;

(11)

assuring ongoing compliance with the terms of first responder agreements;

(12)

assuring that all documents, reports or information provided to the department are current, truthful and correct;

(13)

maintaining compliance with all applicable laws and regulations;

(14)

submission of run response data upon request by department approved method; and

(15)

notification of the department within 10 days if:

(A)

a vehicle is substituted or replaced;

(B)

a vehicle is added, with submission of the nonrefundable fee if applicable; and/or

(C)

there is a change in the:

(i)

number of any designation level in the fleet;

(ii)

official business address;

(iii)

service director;

(iv)

medical director, with submission of the new agreement; and/or

(v)

physical sublocation or station address.

(m)

License renewal process.

(1)

The department shall notify the EMS provider at least 90 days before the expiration date of the current license at the address shown in the current records of the department. It is the responsibility of the provider to notify the department of any change of address. If a notice of expiration is not received, it is the responsibility of the provider to notify the department and request license renewal application information.

(2)

Providers shall submit a completed application and nonrefundable fee, if applicable, and must verify continuing compliance with the requirements of their license.

(3)

If a provider has not met all requirements for a provider license, the provider may apply for a provisional license by submitting a request and, in addition to the regular nonrefundable licensure fee if applicable, a nonrefundable fee of $25. One provisional license, valid for not more than 60 days, may be granted only to prevent probable adverse impact to the health and safety of the service community. Without a provisional license, a provider may not operate if there is a lapse in time between license expiration and license renewal.

(n)

Advertisements. If there are more than five paid staff, but the organization is composed of at least 75% volunteer personnel, the provider shall pay a nonrefundable fee but may continue to advertise the service as volunteer. A provider shall not advertise levels of designation or types of patient care which cannot be provided. Displays on vehicles which indicate the provider's name or the appropriate designation level of the vehicles shall not be considered advertising.

(o)

Surveys. All initial candidates for a provider license shall be required to have a comprehensive survey by the department prior to the license being granted. Surveys may be conducted for cause on any licensed provider.

(p)

Unannounced inspections. Randomly and/or in response to complaints, the department may conduct unannounced inspections to insure compliance of the provider license holder. Inspections may be conducted at any time, including nights or weekends. The department may review all components of provider licensure during an unannounced inspection. Violations or deficiencies may result in disciplinary action as authorized by §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License). The department may grant a reasonable period of time for the provider to correct deficiencies. If the department must reinspect the provider because of noncompliance noted during a previous inspection, the provider shall pay a nonrefundable fee of $25, if applicable.

(q)

Failure to correct identified deficiencies. Failure to correct identified deficiencies within a period of time determined to be reasonable by the department or if the deficiencies are found to be repeated, the provider shall be subject to disciplinary actions in accordance with §157.16 of this title.

§157.12.Rotor-wing Air Ambulance Operations.

(a)

Rotary wing aircraft (helicopters) operated by a licensed emergency medical services (EMS) provider shall be at the mobile intensive care level. Persons or entities operating rotary wing air ambulances must direct and control the integrated activities of both the medical and aviation components. Although the aircraft operator is directly responsible to the Federal Aviation Administration (FAA) for the operation of the aircraft, typically the organization in charge of the medical functions directs the combined efforts of the aviation and medical components during patient transport operations.

(b)

When being used as an ambulance, the helicopter shall:

(1)

be configured so that the medical personnel have adequate access to the patient in order to begin and maintain basic and advanced life support treatment;

(2)

have an entry that allows loading and unloading of a patient without excessive maneuvering (no more than 45 degrees about the lateral axis and 30 degrees about the longitudinal axis); and does not compromise functioning of monitoring systems, intravenous (IV) lines, or manual or mechanical ventilation;

(3)

have a supplemental lighting system in the event standard lighting is insufficient for patient care that includes:

(A)

a self-contained lighting system powered by a battery pack or a portable light with a battery source; and

(B)

a means to protect the pilot's night adaptation vision. (Use of red lighting or low intensity lighting in the patient care area is acceptable if not able to isolate the patient care area);

(4)

have an electric power outlet with an inverter or appropriate power source of sufficient output to meet the requirements of the complete specialized equipment package without compromising the operation of any electrical aircraft equipment;

(5)

have protection of the pilot's flight controls, throttles and radios from any intended or accidental interference by the patient, air medical personnel or equipment and supplies; and

(6)

have an internal medical configuration located so that air medical personnel can provide patient care consistent with the scope of care of the air medical service, to include:

(A)

the space necessary to ensure the patient's airway is maintained and to provide adequate ventilatory support from the secured, seat-belted position of the air medical personnel;

(B)

those aircraft with gaseous oxygen systems have equipment installed so that medical personnel can determine if oxygen is on by in-line pressure gauges mounted in the patient care area. Aircraft using liquid or gaseous oxygen should have equipment installed:

(i)

with each gas outlet clearly marked for identification;

(ii)

with oxygen flow capable of being stopped at the oxygen source from inside the aircraft; and

(iii)

so that the measurement of the liter flow and quantity of oxygen remaining is accessible to air medical personnel while in flight. All flow meters and outlets must be padded, flush mounted, or so located as to prevent injury to air medical personnel; or there shall be an operational policy stating that attendants wear helmets;

(C)

hangers/hooks available to secure (IV) solutions in place or a mechanism to provide high flow fluids if needed:

(i)

all IV hooks shall be padded, flush mounted, or so located as to prevent head trauma to the air medical personnel in the event of a hard landing or emergency with the aircraft; or an operational policy stating that attendants wear helmets; and

(ii)

glass containers shall not be used unless required by medication specifications and properly vented;

(D)

provision for medication which allows for protection from extreme temperatures if it becomes environmentally necessary; and

(E)

secure positioning of cardiac monitors, defibrillators, and external pacers so that displays are visible to medical personnel.

(c)

An air ambulance provider shall meet the responsibilities of EMS providers as in §157.11(l) of this title (relating to Requirements for an EMS Provider License) and in addition shall:

(1)

submit proof that the rotor-wing aircraft provider carries bodily injury and property damage insurance with a company licensed to do business in Texas in order to secure payment for any loss or damage resulting from any occurrence arising out of or caused by the operation or use of any of the certificate holder's aircraft. Coverage amounts shall insure that:

(A)

each aircraft shall be insured for the minimum amount of $1 million for injuries to, or death of, any one person arising out of any one incident or accident;

(B)

the minimum amount of $3 million for injuries to, or death of, more than one person in any one accident; and

(C)

the minimum amount of $500,000 for damage to property arising from any one accident;

(2)

submit proof that the air ambulance provider carries professional liability insurance coverage in the minimum amount of $500,000 per occurrence, with a company licensed to do business in Texas in order to secure payment for any loss or damage resulting from any occurrence arising out of or caused by the care or lack of care of a patient;

(3)

submit a list of all aircraft with the registration number or "N" number for the helicopters in the possession of the provider.

(4)

submit a letter of agreement that all helicopters shall meet the specifications of subsection (b) of this section, if the aircraft is leased from a pool;

(5)

allow visual and physical inspection of each aircraft and of the equipment to be used on each vehicle for the purpose of determining compliance with the vehicle and equipment specifications within this section; and

(6)

submit a copy of current Federal Aviation Administration (FAA) operational certification.

(d)

The air ambulance provider shall designate or employ a medical director who shall meet the following qualifications:

(1)

be a physician approved by the Texas Department of Health and in practice;

(2)

have knowledge and experience consistent with the transport of patients by air;

(3)

be knowledgeable in aeromedical physiology, stresses of flight, aircraft safety, patient care, and resource limitations of the aircraft, medical staff and equipment;

(4)

have access to consult with medical specialists for patient(s) whose illness and care needs are outside the medical director's area of practice; and

(5)

comply with the requirements in Chapter 6, Medicine, Article 4495B, Medical Practice Act, §197.3(a)(2-7) and (b).

(e)

The physician shall fulfill the following responsibilities:

(1)

ensure that there is a comprehensive plan/policy to address selection of appropriate aircraft, staffing and equipment;

(2)

be involved in the selection, hiring, training and continuing education of all medical personnel;

(3)

be responsible for overseeing the development and maintenance of a continuous quality improvement program;

(4)

ensure that there is a plan to provide direction of patient care to the air medical personnel during transport. The system shall include on-line (radio/telephone) medical control, and/or an appropriate system for off-line medical control such as written guidelines, protocols, procedures, patient specific written orders or standing orders;

(5)

participate in any administrative decision making processes that affect patient care;

(6)

ensure that there is an adequate method for on-line medical control, and that there is a well defined plan or procedure and resources in place to allow off-line medical control; and

(7)

oversee the review, revision and validation of written medical policies and protocols annually.

(f)

There shall be two Texas licensed/certified personnel on board the helicopter when in service. A waiver to the Texas license/certification may be granted for personnel employed by providers in New Mexico, Oklahoma, Arkansas, and Louisiana who respond in Texas and are licensed in their respective state. Staffing of vehicles shall be as follows:

(1)

when responding to an emergency scene, at least one of the personnel shall be a paramedic;

(2)

when responding for an inter-facility transfer, at least one of the personnel performing patient care duties shall be a certified or licensed paramedic, registered nurse or physician. The qualifications and numbers of air medical personnel shall be appropriate to patient care needs;

(3)

when responding as in paragraphs (1) and (2) of this subsection, the second person may be a certified or licensed paramedic, registered nurse, or a physician; and

(4)

air medical personnel shall not be assigned or assume the cockpit duties of the flight crew members concurrent with patient care duties and responsibilities.

(g)

Documentation of successful completion of training specific to the helicopter transport environment in general and the licensee's operation specifically shall be required. The curriculum shall be consistent with the Department of Transportation (DOT) Air Medical Crew - National Standard Curriculum or equivalent program and each attendant's qualifications shall be documented.

(h)

Medical supplies and equipment shall be consistent with the service's scope of care as defined in the protocols/standing orders. Medical equipment shall be functional without interfering with the avionics nor should avionics interfere with the function of the medical equipment. Additionally, the following equipment, clean and in working order, must be on the aircraft or immediately available for all providers:

(1)

one or more stretchers capable of being secured in the aircraft which meet the following criteria:

(A)

can accommodate an adult, 6 feet tall, weighing 212 pounds. There shall be restraining devices or additional appliances available to provide adequate restraint of all patients including those under 60 pounds or 36 inches in height;

(B)

shall have the head of the primary stretcher capable of being elevated up to 30 degrees. The elevating section shall not interfere with or require that the patient or stretcher securing straps and hardware be removed or loosened;

(C)

shall be sturdy and rigid enough that it can support cardiopulmonary resuscitation. If a backboard or equivalent device is required to achieve this, such device will be readily available;

(D)

shall have a pad or mattress impervious to moisture and easily cleaned and disinfected according to Occupational Safety and Health Administration (OSHA) bloodborne pathogen requirements; and

(E)

shall have a supply of linen for each patient;

(2)

adequate amounts of oxygen (for anticipated liter flow and length of flight with an emergency reserve) available for every mission;

(3)

one portable oxygen tank;

(4)

a back-up source of oxygen (of sufficient quantity to get safely to a facility for replacements). Back-up source may be the required portable tank if the tank is accessible in the patient care area during flight;

(5)

airway adjuncts as follows:

(A)

oropharyngeal airways in at least five assorted sizes, including adult, child, and infant; and

(B)

nasopharyngeal airways in at least three sizes with water soluble lubricant;

(6)

at least one suction unit which is portable (bulb syringes or foot pump not acceptable);

(7)

the following items in amounts and sizes as specified on a list signed by the medical director:

(A)

IV solutions;

(B)

IV catheters;

(C)

endotracheal tubes;

(D)

medications;

(E)

any specialized equipment required in medical treatment protocols/standing orders;

(F)

pressure bag;

(G)

tourniquets, tape, dressings; and

(H)

container appropriate to contain used sharp devices (needles, scalpels) which meets OSHA requirements;

(8)

assessment equipment as follows:

(A)

equipment suitable to determine blood pressure of the adult, pediatric and infant patient(s) during flight;

(B)

stethoscope;

(C)

penlight/flashlight;

(D)

heavy duty bandage scissors;

(E)

pulse oximeter;

(F)

external cardiac pacing device; and

(G)

IV infusion pump capable of strict mechanical control of an IV infusion drip rate. Passive devices such as dial-a-flow are not acceptable;

(9)

bandages and dressings as follows:

(A)

sterile dressings such as 4x4s, ABD pads;

(B)

bandages such as Kerlix, Kling; and

(C)

tape in various sizes;

(10)

container(s) and methods to collect, contain, and dispose of body fluids such as emesis, oral secretions, and blood consistent with OSHA bloodborne pathogen requirements;

(11)

infection control equipment. The licensee shall have a sufficient quantity of the following supplies for all air medical personnel, and each flight crew member, and all ground personnel with incidental exposure risks according to OSHA requirements which includes but is not limited to:

(A)

protective gloves;

(B)

protective gowns;

(C)

protective eyewear;

(D)

protective face masks;

(E)

an approved bio-hazardous waste plastic bag or impervious container to receive and dispose of used supplies; and

(F)

handwashing capabilities or antiviral towelettes;

(12)

an adequate trash disposal system exclusive of bio-hazardous waste control provisions;

(13)

security of medications, fluids, and controlled substances shall be maintained by each air ambulance licensee in compliance with local, state, and federal drug laws;

(14)

cardiac monitor defibrillator - DC battery powered portable monitor/defibrillator with paper printout, accessories and supplies, with sufficient power supply to meet demands of the mission; and

(15)

quantity and type of drugs and specialized equipment as specified on the medical director's list.

§157.13.Fixed-wing Air Ambulance Operations.

(a)

Fixed wing aircraft operated by a licensed EMS provider shall be at the mobile intensive care level. Persons or entities operating fixed wing air ambulances must direct and control the integrated activities of both the medical and aviation components. Although the aircraft operator is directly responsible to the Federal Aviation Administration (FAA) for the operation of the aircraft, one organization, typically the one in charge of the medical functions, directs the combined efforts of the aviation and medical components during patient transport operations.

(b)

When being used as an ambulance, a fixed wing aircraft shall:

(1)

be multi-engine or be a single, turbo-prop engine capable of maintaining cabin pressurization;

(2)

maintain a cabin altitude consistent with patient diagnosis, condition, and destination;

(3)

be equipped and kept current for instrument flight rules (IFR) flight;

(4)

have a door large enough to allow a patient on a stretcher to be enplaned without excessive maneuvering or tipping of the patient which compromises the function of monitoring devices, intravenous (IV) lines or ventilation equipment;

(5)

be designed or modified to accommodate at least one stretcher patient;

(6)

have a lighting system which can provide adequate intensity to illuminate the patient care area and an adequate method (curtain, distance) to limit the cabin light from entering the cockpit and impeding cockpit crew vision during night operations;

(7)

have an environmental system (heating and cooling) capable of maintaining a comfortable temperature at all times;

(8)

have an interior cabin configuration large enough to accommodate the number of air medical personnel needed to provide care to the patient, as well as an adult stretcher in the cabin area with access to the patient. The configuration shall not impede the normal or emergency evacuation routes;

(9)

have an electrical system capable of servicing the power needs of electrically powered on-board patient care equipment;

(10)

have all installed and carry-on equipment secured using FAA-approved devices and methods;

(11)

have sufficient space in the cabin area where the patient stretcher is installed so that equipment can be stored and secured with FAA-approved devices in such a manner that it is accessible to the air medical personnel; and

(12)

have two fire extinguishers approved for aircraft use. Each shall be fully charged with valid inspection certification and capable of extinguishing type A, B, or C fires. One extinguisher shall be accessible to the cockpit crew and one shall be in the cabin area accessible to the medical crew member.

(c)

An operator of aircraft in an air ambulance program shall be FAA certified as an air taxi and commercial operator (ACTO) with operation specifications allowing air ambulance operations.

(d)

The fixed-wing air ambulance provider shall meet the responsibilities of EMS providers as in §157.11(l) of this title (relating to Requirements for an EMS Provider License) and shall also:

(1)

submit proof that the fixed-wing aircraft provider carries bodily injury and property damage insurance with a company licensed to do business in Texas, in order to secure payment for any loss or damage resulting from any occurrence arising out of or caused by the operation or use of any of the certificate holder's aircraft. Coverage amounts shall insure that:

(A)

each aircraft shall be insured for the minimum amount of $1 million for injuries to, or death of, any one person arising out of any one incident or accident;

(B)

the minimum amount of $3 million for injuries to, or death of, more than one person in any one accident; and

(C)

for the minimum amount of $500,000 for damage to property arising from any one accident;

(2)

submit proof that the air ambulance provider carries professional liability insurance coverage in the minimum amount of $500,000 per occurrence, with a company licensed to do business in Texas in order to secure payment for any loss or damage resulting from any occurrence arising out of or caused by the care or lack of care of a patient; and

(3)

submit a letter of agreement that all fixed-wing aircraft shall meet the specifications of subsection (b) of this section, if the aircraft is leased from a pool; and

(4)

submit a copy of current Federal Aviation Administration Air Taxi and Commercial Operator Certification.

(e)

The air ambulance provider shall designate or employ a medical director who shall meet the following qualifications:

(1)

be a physician approved by the Texas Department of Health and in practice;

(2)

have knowledge and experience consistent with the transport of patients by air;

(3)

be knowledgeable in aeromedical physiology, stresses of flight, aircraft safety, patient care, and resource limitations of the aircraft, medical staff and equipment;

(4)

have access to consult with medical specialists for patient(s) whose illness and care needs are outside the medical director's area of practice; and

(5)

shall comply with the requirements in Chapter 6, Medicine, Article 4495b, Medical Practice Act, §197.3 subparagraphs (a)(2)-(7) and (b).

(f)

The physician shall fulfill the following responsibilities:

(1)

ensure that there is a comprehensive plan/policy to address selection of appropriate aircraft, staffing and equipment;

(2)

be involved in the selection, hiring, training and continuing education of all medical personnel;

(3)

be responsible for overseeing the development and maintenance of a continuous quality improvement program;

(4)

ensure that there is a plan to provide direction of patient care to the air medical personnel during transport. The system shall include on-line (radio/telephone) medical control, and/or an appropriate system for off-line medical control such as written guidelines, protocols, procedures, patient specific written orders or standing orders;

(5)

participate in administrative decision making processes that affect patient care;

(6)

ensure that there is an adequate method for on-line medical control, and that there is a well defined plan or procedure and resources in place to allow off-line medical control; and

(7)

oversee the review, revision and validation of written policies and protocols annually to include a policy defining the specific instances in which a patient could be accompanied by only one attendant.

(g)

There shall be at least one licensed or certified paramedic, registered nurse, or physician on board an air ambulance to perform patient care duties on that air ambulance. The qualifications and numbers of air medical personnel shall be appropriate to patient care needs. Personnel employed by providers who are based in another state, do not need Texas certification/licensure but shall be certified/licensed in their respective state.

(1)

Documentation of successful completion of training specific to the fixed-wing transport environment in general and the licensee's operation specifically shall be required. The curriculum shall be consistent with the Department of Transportation (DOT) Air Medical Crew- National Standard Curriculum, or equivalent program.

(2)

Each attendant's qualifications shall be documented.

(3)

Air medical personnel shall not be assigned or assume the cockpit duties of the flight crew members concurrent with patient care duties and responsibilities.

(4)

The aircraft shall be operated by a pilot or pilots certified in accordance with applicable Federal Aviation Regulations.

(h)

Medical supplies and equipment shall be consistent with the service's scope of care as defined in the protocols/standing orders. Medical equipment shall be functional without interfering with the avionics nor should avionics interfere with the function of the medical equipment. Additionally, the following equipment, clean and in working order, must be on the aircraft or immediately available for all providers:

(1)

one or more stretchers installed in the aircraft cabin which meet the following criteria:

(A)

can accommodate an adult, 6 feet tall, weighing 212 pounds except for a neonatal stretcher which has been fitted with an isolette. There shall be restraining devices or additional appliances available to provide adequate restraint of all patients including those under 60 pounds or 36 inches in height;

(B)

the head of each stretcher shall be capable of being elevated up to 45 degrees. The elevating section must hinge at or near the patient's hips and shall not interfere with or require that the patient or stretcher securing straps and hardware be removed or loosened;

(C)

each stretcher shall be positioned in the cabin to allow the air medical personnel clear view of the patient and shall ensure that medical personnel always have access to the patient's head and upper body for airway control procedures as well as sufficient space over the area where the patients chest is to adequately perform closed chest compression or abdominal thrusts on the patient;

(D)

a pad or mattress impervious to moisture and easily cleaned and disinfected according to Occupation Safety and Health Administration (OSHA) bloodborne pathogen requirements;

(E)

a device to make the stretcher surface rigid enough if the surface of the stretcher under the patient's torso is not firm enough to support adequate chest compressions; and

(F)

shall have a supply of linen for each patient;

(2)

an adequate and manually-controlled supply of gaseous or liquid medical oxygen, attachments for humidification, and a variable flow regulator for each patient;

(A)

a humidifier, if used, shall be a sterile, disposable, one-time usage item;

(B)

the licensee shall have and demonstrate the method used to calculate the volume of oxygen required to provide sufficient oxygen for the patients needs for the duration of the transport;

(C)

the licensee shall have a plan to provide the calculated volume of oxygen plus a reserve equal 1000 liters or the volume required to reach an appropriate airport, whichever is longer;

(D)

all necessary regulators, gauges and accessories shall be present and in good working order;

(E)

the oxygen system shall be securely fastened to the airframe using FAA-approved restraining devices;

(i)

a separate emergency backup supply of oxygen of not less than 57 liters with regulator and flow meter;

(ii)

one adult, one pediatric size non-rebreathing mask, one adult size nasal cannula and necessary connective tubings and appliances.

(3)

an electrically-powered suction apparatus with wide bore tubing, a large reservoir and various sizes suction catheters. The suction system may be built into the aircraft or provided with a portable unit. Backup suction is required and can be a manually operated device. (Bulb syringe not acceptable);

(4)

hand operated bag-valve-mask ventilators of adult, pediatric and infant sizes with clear masks in adult, pediatric and infant sizes. It shall be capable of use with a supplemental oxygen supply and have an oxygen reservoir;

(5)

airway adjuncts as follows:

(A)

oropharyngeal airways in at least five assorted sizes, including adult, child and infant; and

(B)

nasopharyngeal airways in at least three sizes with water soluble lubricant;

(6)

assessment equipment as follows:

(A)

equipment suitable to determine blood pressure of the adult, pediatric and infant patient(s) during flight;

(B)

stethoscope;

(C)

penlight/flashlight;

(D)

heavy duty bandage scissors; and

(E)

pulse oximeter;

(7)

bandages and dressings as follows:

(A)

sterile dressings such as 4x4s, ABD pads;

(B)

bandages such as Kerlix, Kling; and

(C)

tape in various sizes.

(8)

container(s) and methods to collect, contain, and dispose of body fluids such as emesis, oral secretions, and blood consistent with OSHA bloodborne pathogen requirements;

(9)

urinal and bedpan with toilet tissue;

(10)

infection control equipment. The licensee shall have a sufficient quantity of the following supplies for all air medical personnel, each flight crew member, and all ground personnel with incidental exposure risks according to OSHA requirements which includes but is not limited to:

(A)

protective gloves;

(B)

protective gowns;

(C)

protective eyewear;

(D)

protective face masks;

(E)

an approved bio-hazardous waste plastic bag or impervious container to receive and dispose of used supplies; and

(F)

handwashing capabilities or antiviral towelettes.

(11)

an adequate trash disposal system exclusive of bio-hazardous waste control provisions;

(12)

the following additional equipment in amounts and sizes specified by the medical director is required for an air ambulance provider to function at the advanced level:

(A)

advanced airway management equipment appropriate to the patient's needs;

(B)

sterile crystalloid solutions in plastic containers, IV catheters, and administration tubing sets;

(C)

hanger for IV solutions;

(D)

pressure bag;

(E)

tourniquets, tape, dressings;

(F)

container appropriate to contain used sharp devices, needles, scalpels which meets OSHA requirements;

(G)

a list signed by medical director defining quantities and types of drugs to be carried; and

(H)

any specialized equipment required in medical treatment protocols/standing orders.

(13)

cardiac monitor defibrillator-DC battery powered portable monitor/defibrillator with paper printout, accessories and supplies, with sufficient power supply to meet demands of the mission; and

(14)

survival kit which shall include, but not be limited to, the following items which are appropriate to the terrain and environments the provider operates over:

(A)

instruction manual;

(B)

water;

(C)

shelter-space blanket;

(D)

knife;

(E)

signaling devices;

(F)

compass; and

(G)

fire starting items.

(i)

A system for security of medications, fluids, and controlled substances shall be maintained by each air ambulance licensee in compliance with local, state, and federal drug laws.

(j)

The air ambulance provider shall own the following equipment or shall have a written lease agreement explaining the availability of the equipment for use when the patient's condition indicates the need:

(1)

external cardiac pacing device;

(2)

IV infusion pump capable of strict mechanical control of an IV infusion drip rate. Passive devices such as dial-a-flow are not acceptable; and

(3)

a mechanical ventilator that can deliver up to 100 % oxygen concentration at pressures, rates and volumes appropriate for the size of the patient.

§157.14.Requirements for First Responder Organization Registration.

(a)

First Responders Organization. First Responders Organizations (FRO's) are individuals or organizations which:

(1)

routinely respond to emergency situations;

(2)

utilize personnel who are emergency medical services (EMS) certified by the Texas Department of Health (department);

(3)

provide on-scene patient care; and

(4)

do not transport patients.

(b)

Application requirements. The applicant shall submit a completed application to the department. A complete application consists of the following:

(1)

the application;

(2)

a personnel list to include social security number and certification/licensure level;

(3)

description or map of the service area;

(4)

agreements with appropriate licensed providers; and

(5)

a nonrefundable application fee, if applicable.

(A)

Any FRO which is, or has a contract with, an entity such as a business, corporation or department and whose first responder employees or members are compensated by that entity for providing first responder service shall pay a nonrefundable $50 application fee. If the registration is issued for less than 12 months in which case the nonrefundable fee shall be $25. The FRO's personnel are not exempt from the payment of certification application fees.

(B)

Applicants who meet all the requirements for registration shall be issued a First Responder registration. The registration may be valid for up to 2 years, but may be issued for less than 2 years for administrative purposes.

(c)

The FRO/provider agreement.

(1)

The FRO shall have an agreement with all licensed providers and their medical directors who routinely transport patients treated by the FRO's personnel. The agreement shall be approved by the responsible person for the first responder organization, the service director and the medical director of the licensed EMS provider.

(2)

The agreements shall address at a minimum the:

(A)

level(s) of certification of FRO personnel providing care;

(B)

protocols and medical equipment used by the FRO which must be approved by the medical director of the licensed transporting providers with whom the FRO has agreements;

(C)

days of the week and hours of the day the FRO will be available for response;

(D)

patient care reporting procedures;

(E)

certification of FRO personnel who render patient care;

(F)

process for the assessment of care provided by the FRO personnel;

(G)

response code policies for FRO personnel;

(H)

on-scene chain-of-command policies;

(I)

policies regarding FRO personnel canceling en route EMS units;

(J)

policies regarding FRO personnel accompanying patients in provider's vehicles; and

(K)

patient confidentiality.

(d)

Responsibilities of the FRO. During the registration period the FRO's responsibilities shall include:

(1)

assuring ongoing compliance with the terms of the provider agreement(s);

(2)

assuring that all personnel, when on-scene, are prominently identified by name, certification level and organization;

(3)

monitoring and taking appropriate action regarding the quality of patient care provided by FRO personnel;

(4)

monitoring personnel compliance with medical protocols;

(5)

maintaining confidentiality of patient information according to the Health and Safety Code, Chapter 773, Subchapter D, §§773.091-773.096;

(6)

carrying proof of first responder registration in all vehicles used or operated by the FRO;

(7)

maintaining compliance with all applicable laws and regulations;

(8)

monitoring and enforcing general personnel safety policies including at least personal protective equipment, immunizations and communicable disease exposure and emergency vehicle operation;

(9)

notifying the department within 10 days if:

(A)

the FRO ceases to exist or merges with another FRO;

(B)

there is a change in the:

(i)

official business address and/or phone number;

(ii)

administrator;

(iii)

providers associated with the FRO; and/or

(iv)

medical director.

(e)

Registration renewal process.

(1)

The department shall notify the FRO at least 90 days before the expiration date of the current registration at the address shown in the current records of the department. If a notice of expiration is not received, it is the responsibility of the FRO to notify the department and request registration renewal application information.

(2)

FRO's shall submit a completed application and nonrefundable fee, if applicable, and must verify compliance with the requirements of their registration.

(f)

Registration denial. Registration may be denied for, but not limited to, the following reasons:

(1)

failure to meet requirements of first responder registration in accordance with subsections (b) and (c) of this section;

(2)

previous failure to meet the responsibilities of a registered first responder organization as described in subsection (d) of this section;

(3)

falsifying any information, record or document required for a first responder registration;

(4)

misrepresenting any requirements for first responder registration or renewal of first responder registration;

(5)

history of criminal activity while registered as an FRO;

(6)

history of disciplinary action relating to first responder registration; and/or

(7)

issuing a check for application for first responder registration which is subsequently returned to the department unpaid.

(g)

Registration revocation criteria. First responder registration may be revoked or suspended for failure to meet the responsibilities of a registered FRO as described in subsection (d) of this section.

§157.16.Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License.

(a)

Emergency Suspension. The bureau chief, Bureau of Emergency Management (bureau), may issue an emergency suspension order to any licensed emergency medical services (EMS) provider if the bureau chief has reasonable cause to believe that the conduct of any licensed provider creates an imminent danger to public health or safety.

(1)

An emergency suspension issued by the bureau chief is effective immediately without a hearing or notice to the license holder. Notice to the license holder shall be presumed established on the date that a copy of the signed emergency suspension order is sent to the individual listed as the administrator of the service at the address shown in the current records of the department.

(2)

A copy of the emergency suspension order shall be sent to the provider's listed medical director and to any and all government entities, institutions or facilities with which the license holder is known to be associated to the addresses shown in the current records of the department.

(3)

If a written request for a hearing is received from the suspended license holder within 15 days of the date of notice, the department shall conduct a hearing not later than the thirtieth day after the date on which a hearing request is received to determine if the emergency suspension is to be continued, modified or rescinded. The hearing and appeal from any disciplinary action related to the hearing shall be governed by the Administrative Procedure Act, Government Code, Chapter 2001.

(b)

Administrative penalty. An administrative penalty may be assessed when an EMS provider is in violation of the Health and Safety Code, Chapter 773, 25 TAC Chapter 157, or the reasons outlined in subsections (c) and (d) of this section.

(c)

Accountability. A provider retains ultimate responsibility for the operation of the service. A licensed EMS provider may not claim a defense when one or more staff members, acting with or without the consent and knowledge of the license holder, commit(s) multiple violations in this section, or perform(s) contrary to EMS standards while on EMS business for the provider.

(d)

Nonemergency suspension or revocation. An EMS provider license may be suspended or revoked for, but not limited to, the following reasons:

(1)

failing to comply with any requirement of provider licensure as defined in §157.11 of this title (relating to Requirements for an EMS Provider License);

(2)

operating the service while the license is under suspension;

(3)

falsifying or altering a license issued by the department;

(4)

failing to correct deficiencies as instructed by the department;

(5)

obtaining or attempting to obtain or assisting another to obtain a provider license or personnel certification by fraud, forgery, deception, or misrepresentation;

(6)

providing false or misleading advertising and/or making false or misleading claims to clients or the public about the service;

(7)

failing to operate a subscription service/membership program according to provisions in §157.11 of this title;

(8)

failing to maintain patient confidentiality according to standards and department regulations;

(9)

discriminating in the provision of services based on national origin, race, color, creed, religion, gender, sexual orientation, age, physical or mental disability, or economic status;

(10)

falsifying a patient care record or any other document or record resulting from or pertaining to EMS Provider responsibilities;

(11)

obtaining any fee or benefit by fraud, coercion, theft, deception, or misrepresentation;

(12)

failing to give the department true and complete information when asked, regarding any alleged or actual violation of the Health and Safety Code, Chapter 773, or the rules adopted thereunder or failing to report such a violation;

(13)

failing to pay an administrative penalty in full within established time frames;

(14)

failing to staff each vehicle deemed to be in service or response ready with appropriately and currently certified personnel;

(15)

operating, directing, or allowing staff to operate vehicle warning devices unnecessarily or inappropriately;

(16)

operating, directing, or allowing any person to operate any vehicle on EMS business while under the influence of any substance that inhibits the mental or physical capacities of that person;

(17)

having been found to have operated, directed, or allowed staff to operate any vehicle while on EMS business in a reckless or unsafe manner and/or in a manner that is dangerous to the health or safety of any person;

(18)

operating, directing, or allowing staff to operate any vehicle that is not mechanically safe, clean and in good operating condition; and/or

(19)

having been found in violation of any local, state, or national code or regulation pertaining to EMS operations or business practices; and/or violating any rule or standard that could jeopardize the health or safety of any person;.

(e)

Denial of a license. A license may be denied for, but not limited to, the following reasons:

(1)

failing to meet the licensing requirements outlined in §157.11 of this title;

(2)

one of the owners having a history of a misdemeanor or felony which the department has determined may put the safety of any person; at risk;

(3)

previous conduct while holding an EMS provider license which could put any person at risk;

(4)

EMS provider in another state;

(5)

falsifying or misrepresenting any fact or requirement on or for an application or related document for a provider license or EMS personnel license/certificate; and/or

(6)

issuing a check for application for a provider license which is returned to the department unpaid.

(f)

Notification. If the department proposes to deny, suspend, revoke, or probate a license, the license holder shall be notified at the address shown in the current records of the department. The notice shall state the alleged facts or conduct to warrant the proposed action and state that the license holder may request a hearing.

(g)

Hearing Request.

(1)

A request for a hearing shall be in writing and submitted to the bureau chief and postmarked within 15 days after the date of the notice. The hearing shall be conducted pursuant to the Administrative Procedure Act, Government Code, Chapter 2001.

(2)

If the candidate, applicant or licensee does not request a hearing in writing within 15 days after proper notice, the individual is deemed to have waived the opportunity for a hearing as outlined in the notice.

(h)

Probation. The department may probate any penalty assessed under this section and may specify terms and conditions of any probation issued.

(i)

Re-application.

(1)

Two years after denial or revocation of a license, or the voluntary surrender of a license while disciplinary action is pending, an individual may petition the department in writing for re-application for licensure. Expiration of a certificate or license during the suspension period shall not affect the two-year waiting period required before a petition can be submitted.

(2)

The petitioner bears the burden of proving fitness for licensure.

(3)

The department may allow an application for licensure if there is proof that the health, safety, and confidence of the public will be protected.

(4)

The department may deny any petitioner if, in the judgement of the bureau chief, the reason for the original action continues to exist or if the petitioner has failed to offer sufficient proof that there is no longer a threat to public health, safety, and/or confidence.

(5)

If the application is allowed, the petitioner shall be required to meet the requirements as described in §157.11 of this title and in addition shall meet the terms of probation in subsection (h) of this section.

(j)

Expiration of a license during suspension. A provider whose license expires during a suspension period shall not reapply for licensure until the end of the suspension period.

(k)

Surrender of a license. Surrender of a license shall not deprive the department of jurisdiction in regard to disciplinary action against the license holder. A provider who wishes to surrender his or her license prior to the expiration of the license may do so by:

(1)

completing a Surrender of License statement; and

(2)

in the event that a disciplinary action is pending or reasonably imminent, the licensee shall acknowledge that the surrender constitutes a plea of "no contest" to the allegations upon which the disciplinary action is predicated, acknowledging that the surrender is a "no contest" plea in the event that a disciplinary action is pending or reasonably imminent.

(l)

Notification of disposition. An order of final disposition of any disciplinary action shall be sent to the license holder at the address shown in the current records of the department. A copy of the order shall also be sent to the provider's medical director and to any government entity, institution or facility with which the license holder is known to be associated at the address shown in the current records of the department.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002569

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.32 - 157.35

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002570

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (5120 458-7236

25 TAC §§157.33, 157.36, 157.37

The new rules are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

§157.33. Certification.

(a)

Certification requirements. A candidate for emergency medical services (EMS) certification shall:

(1)

be at least 18 years of age;

(2)

have a high school diploma or GED certificate;

(3)

have successfully completed a Texas Department of Health (department)- approved course; and

(4)

submit an application and the following nonrefundable fees as applicable:

(A)

$50 for emergency care attendant (ECA) or emergency medical technician (EMT);

(B)

$75 for EMT-intermediate (EMT-I) or EMT-paramedic (EMT-P); and

(C)

EMS volunteer - no fee. However, if such an individual receives compensation during the certification period, the exemption ceases and the individual shall pay a prorated fee to the department based on the number of years remaining in the certification period when employment begins. The nonrefundable fee for ECA or EMT certification shall be $12.50 per each year remaining in the certification. The nonrefundable fee for EMT-I or EMT-P shall be $18.75 per each year remaining in the certification. Any portion of a year will count as a full year; and

(5)

pass the department's written examination or the National Registry examination.

(b)

Length of certification. A candidate who meets the requirements of subsection (a) of this section shall be certified for four years beginning on the date of issuance of a certificate and wallet-size certificate.

(c)

Scheduling authority for certification examinations.

(1)

The department has final authority for scheduling all certification examination sessions.

(2)

Examinations shall be administered at regularly scheduled times in regional test centers.

(3)

The candidate shall be responsible for making appropriate arrangements for the examination.

(4)

The department is not required to set special examination schedules for a single candidate or for a specific group of candidates.

(d)

Time limits for completing requirements.

(1)

A candidate shall complete all requirements for certification no later than one year after the candidate's course completion date.

(2)

A candidate who does not complete all requirements for certification within one year of the candidate's initial course completion date must meet the requirements of subsection (a) of this section including the completion of another initial course to achieve certification.

(e)

Retesting.

(1)

A candidate who does not pass the department's written examination may retest after:

(A)

submitting an application to retest; and

(B)

paying a nonrefundable fee of $25, if applicable.

(2)

A candidate who does not pass a retest may request a second retest after:

(A)

submitting documentation that verifies completion of a formal refresher course;

(B)

submitting an application to retest; and

(C)

paying a nonrefundable fee of $25, if applicable.

(3)

A candidate who does not pass a second retest must meet the requirements of subsection (a) of this section which includes completion of another initial course to achieve certification.

(f)

Prolonged application process by the department. If the application approval process is prolonged due to a felony/misdemeanor conviction investigation or other administrative procedure within the department, the time period for determination of certification eligibility will be extended to reasonably accommodate the candidate and/or the department.

(g)

Non-transferability of certificate. A certificate is not transferable. A duplicate certificate may be issued if requested with a nonrefundable fee of $5.

(h)

Completion of higher level courses. Individuals who successfully complete certification requirements for a higher level of certification are considered certified only at the higher level. The completion of a course at a higher level of certification shall satisfy the course completion requirements for a lower level of certification, and the individual may apply for certification at the lower level by following the procedure listed in subsections (a)-(c) of this section.

(i)

Voluntary downgrades. An individual who holds EMS certification may be certified at a lower level voluntarily for the remainder of a current certification by submitting an application for certification and the applicable nonrefundable fee as required in subsection (a)(4) of this section;

(j)

Recertification.

(1)

A certificant shall meet the following requirements for recertification. The certificant shall:

(A)

complete the continuing education (CE) requirements for recertification as required in this title (relating to Continuing Education) prior to the expiration of the certificate and prior to meeting the requirement in subparagraph (D) of this paragraph;

(B)

submit to the department an application for recertification and the nonrefundable fee as set out in subsection (a)(4) of this section; and

(C)

complete the department's CE evaluation which shall be an attempt to measure the individual's knowledge necessary for the adequate provision of emergency care for current level of certification. The department has final authority for scheduling all written CE evaluation sessions.

(2)

After verification by the department of the information submitted by the certificant, a certificant who meets requirements of this subsection will be recertified for four years commencing on the day following the expiration date of the most recent certificate. A new certificate and wallet-sized certificate signed by department officials shall be issued.

(3)

The results of the CE evaluation along with information relevant to interpretation of the scores will be issued to the recertifying candidate, associated medical directors, providers, first responder organizations, and/or employers.

(4)

One re-evaluation may be taken. A fee of $25 shall accompany the request for a re- evaluation. The re-evaluation results will be issued as in paragraph (3) of this subsection.

(5)

In conjunction with the certificant's two-year interim CE reporting cycle, the certificant may elect to complete the CE evaluation or the certificant's medical directors, providers, first responder organizations and/or employers may mandate that the certificant complete the CE evaluation and, if applicable, one re-evaluation. The first CE evaluation shall be completed within 180 days after the deadline date of the interim two-year reporting cycle. The re-evaluation may be completed after the 180-day period. The CE evaluation results will be issued as described in paragraph (3) of this subsection.

(6)

To take a two-year interim CE evaluation, the certificant shall submit an application, and a nonrefundable fee as set out in subsection (a)(4) of this section. A fee of $25 shall accompany the request for a re-evaluation.

(k)

Reentry or late recertification.

(1)

Reentry is the process for regaining EMS certification:

(A)

after the certificate has been surrendered;

(B)

during a period of inactive status;

(C)

when an application for renewal is postmarked after the expiration of the most recent certificate; or

(D)

when all requirements for recertification are not met prior to the end of the latest certification period.

(2)

Late recertification.

(A)

The candidate shall be considered as non-certified and may not function in the capacity of an EMS certificant or represent that he is EMS certified until recertification is issued.

(B)

A candidate whose certificate has been expired for 90 days or less may renew the certificate by submitting an application and paying to the department a nonrefundable renewal fee that is equal to 1 1/2 times the normally required application renewal fee for that level as listed in subsection (a)(4) of this section.

(C)

A candidate whose certificate has been expired for more than 90 days but less than one year may renew the certificate by submitting an application and paying to the department a nonrefundable renewal fee that is equal to two times the normally required application renewal fee as listed in subsection (a)(4) of this section. A candidate shall submit documentation that verifies completion of a formal refresher course.

(D)

A candidate shall pass the department's written exam.

(E)

A candidate whose certificate has been expired for one year or more may not renew the certificate. The candidate may become certified by complying with the requirements of subsection (a) of this section including the successful completion of another initial course.

(F)

A candidate who was certified in this state, moved to another state, and is currently certified or licensed and has been in practice in the other state for the two years preceding the date of application may become certified without reexamination. The candidate must pay to the department a nonrefundable fee that is equal to two times the normally required renewal fee for certification as listed in subsection (a)(4) of this section.

(l)

Inactive status. A certified EMT, EMT-I, or EMT-P may make application to the department for inactive status at any time during or after the certification period so long as the certification can be verified by department.

(1)

The request for inactive status shall be accompanied by a nonrefundable fee of $25 in addition to the regular nonrefundable application fee.

(2)

The initial inactive status period shall remain in effect until the end of the current certification period for those candidates who are currently certified and may be renewable every four years thereafter by submitting an application and the appropriate nonrefundable fee as in subsection (a)(3) of this section.

(3)

The initial inactive status period shall remain in effect for four years from the date of issuance for those candidates not currently certified.

(4)

While on inactive status, a person shall not practice other than to act as a bystander rendering first aid or cardiopulmonary resuscitation (CPR). Practicing in any other capacity for compensation or as a volunteer shall be cause for denial of reentry and decertification.

(m)

Reciprocity. A person currently certified by the National Registry or in another state may be certified by submitting an application and a nonrefundable fee of $100.

(1)

After evaluation of the application and verification of the certification by the department, the candidate will be certified for one year.

(2)

Prior to the expiration of the one-year certification, the certificant shall:

(A)

submit a completed personnel certification application and a nonrefundable fee as in subsection (a)(4) of this section;

(B)

complete 25 percent of the CE requirement for the appropriate level as indicated in this title or complete a refresher course at the appropriate level; and

(C)

pass the department's written examination.

(3)

A candidate who fails the written examination may retest one time after:

(A)

submitting an application to retest; and

(B)

paying a nonrefundable fee of $25.

(4)

The retest shall be completed no later than the end of the one-year certification period.

(5)

After verification by the department of the information submitted, a candidate who meets the requirements of this section shall be certified for four years beginning on the date of issuance of the certificate.

(6)

A candidate who does not complete the requirements for certification before the expiration date of the one-year certificate or who fails a retest shall meet the requirements of subsection (a) of this section including the successful completion of another initial course as applicable to achieve certification.

(n)

Equivalency.

(1)

A candidate for certification who completed EMS training outside the United States or its possessions, or a candidate who is certified or licensed in another healthcare discipline shall:

(A)

be at least 18 years of age;

(B)

submit a copy of the curriculum completed by the candidate for review by a regionally accredited post secondary institution approved by the department to sponsor an EMS education program;

(C)

document correction of any deficiencies identified during review of the curriculum by submitting evidence of remedial training from a department approved EMS education program;

(D)

submit an application and appropriate nonrefundable fee listed in subsection (a) of this section to the department; and

(E)

pass the department's written examination.

(2)

Evaluations of curricula conducted by post secondary educational institutions under this subsection shall be consistent with the institution's established policies and procedures for awarding credit by transfer or advanced placement.

(o)

Military personnel. A person certified by the department who is deployed in support of military, security, or other action by the United Nations Security Council, a national emergency declared by the president of the United States, or a declaration of war by the United States Congress is eligible for recertification under timely recertification requirements, from the person's date of demobilization until one calendar year after the date of demobilization but will not be certified during that period.

§157.36. Criteria for Denial and Disciplinary Actions for EMS Personnel and Voluntary Surrender of a Certificate or License.

(a)

Emergency Suspension. The Bureau Chief, Bureau of Emergency Management (bureau), may issue an emergency suspension order to any emergency medical services (EMS) certificant or licensee if the bureau chief has reasonable cause to believe that the conduct of any certificant or licensee creates an imminent danger to public health or safety.

(1)

An emergency suspension issued by the bureau chief shall be effective immediately without a hearing or notice to the certificant or licensee. Notice to the certificant or licensee shall be established on the date that a copy of the signed emergency suspension order is sent to the address shown in the current records of the department.

(2)

A copy of the emergency suspension order shall be sent to any licensed EMS provider, first responder organization, medical director, institution or facility with which the certificant or licensee is known to be associated, at the address shown in the current records of the department.

(3)

If a written request for a hearing is received from the suspended individual within 15 days of the date of suspension, the department shall conduct a hearing not later than the thirtieth day after the date on which a hearing request is received to determine if the emergency suspension is to be continued, modified or rescinded. The hearing and appeal from any disciplinary action related to the hearing shall be governed by the Administrative Procedure Act, Government Code, Chapter 2001.

(b)

Nonemergency suspension, decertification and revocation of a certificant or paramedic licensee. The department may suspend or decertify an EMS certificant or suspend or revoke a licensed paramedic for, but not limited to, the following reasons:

(1)

violating any provision of the Health and Safety Code, Chapter 773, and/or Title 25 of the Texas Administrative Code (TAC), as well as Federal, State, or local laws, rules or regulations affecting, but not limited to, the practice of EMS;

(2)

any conduct which is criminal in nature and/or any conduct which is in violation of any criminal, civil and/or administrative code or statute;

(3)

failing to make accurate, complete and/or clearly written patient care reports documenting a patient's condition upon arrival at the scene, the prehospital care provided, and patient's status during transport, including signs, symptoms, and responses during duration of transport;

(4)

falsifying any EMS record; patient record or report; or making false or misleading statements in a oral report; or destroying a patient care report;

(5)

disclosing confidential information or knowledge concerning a patient except where required or allowed by law;

(6)

causing or permitting physical or emotional abuse or injury to a patient or the public, and/or failing to report such abuse or injury to the employer, appropriate legal authority and/or the department;

(7)

performing advanced level or invasive treatment without medical direction or supervision, or practicing beyond the scope of certification or licensure;

(8)

failing to respond to a call while on duty and/or leaving duty assignment without proper authority;

(9)

abandoning a patient, turning over the care of a patient or delegating EMS functions to a person who lacks the education, training, experience, knowledge to provide appropriate level of care for the patient;

(10)

failing to comply with the terms of a department ordered probation or suspension;

(11)

issuing a check to the department which has been returned to the department or its agent unpaid;

(12)

discriminating in any way based on real or perceived conditions of national origin, race, color, creed, religion, sex, sexual orientation, age, physical disability, mental disability, or economic status;

(13)

misrepresenting level of any certification or licensure;

(14)

misappropriating medications, supplies, equipment, personal items, or money belonging to the patient, employer or any other person or entity or failing to take reasonable precautions to prevent such misappropriations;

(15)

falsifying or altering, or assisting another in falsifying or altering, any department application, EMS certificate or license; or using or possessing any such altered certificate or license;

(16)

committing any offense during the period of a suspension/probation or repeating any offense for which a suspension/probation was imposed within the two-year period immediately following the end of the suspension or probation;

(17)

cheating and/or assisting another to cheat on any department examination or the examination of any provider licensed by the department or any institution or entity conducting EMS training;

(18)

obtaining or attempting to obtain and/or assisting another in obtaining or attempting to obtain, any advantage, benefit, favor or gain by fraud, forgery, deception, misrepresentation, untruth or subterfuge;

(19)

illegally possessing, dispensing, administering or distributing, or attempting to illegally dispense, administer, or distribute controlled substances as defined by the Health and Safety Code, Chapter 481 and/or Chapter 483;

(20)

having an EMS certificate or license or another health provider certificate or license suspended or revoked in another state, while holding a Texas EMS certificate or license;

(21)

failing or refusing to give the department full and complete information and cooperation, upon request;

(22)

failing to notify the department within 30 days of final sentencing of any criminal offense which resulted in final conviction as defined in §157.37(c) of this title (relating to Certification or Licensure of Persons With Criminal Backgrounds);

(23)

having been convicted of any misdemeanor or felony in accordance with the provisions of §157.37 of this title;

(24)

failing to complete any portion, including submission of fingerprints, of the criminal history evaluation process within 60 days of notification to do so, in accordance with provisions in §157.37 of this title;

(25)

failing to notify the department within 10 days of an arrest for any alcohol or drug related offense;

(26)

engaging in any conduct that jeopardizes or has the potential to jeopardize the health or safety of any person;

(27)

abusing alcohol or drugs to such an extent that, in the opinion of the bureau chief, the health or safety of any person is, or may be, endangered;

(28)

engaging in any activity that betrays the public trust and confidence in EMS; and

(29)

engaging in any conduct listed in §157.37(a)-(c) of this title whether or not resulting in a conviction.

(c)

Criteria for denial of certification, or licensure. A certificate or license may be denied for, but not limited to, the following reasons:

(1)

failing to meet standards as required in this section;

(2)

previous conduct on the part of the applicant during the performance of duties relating to the responsibilities of EMS personnel that is contrary to accepted standards of conduct as described in this section;

(3)

conviction of a crime which directly relates to the profession of EMS personnel as described in §157.37 of this title;

(4)

disciplinary action relating to a certificate or license issued in another state;

(5)

falsifying any Texas application for certification or licensure or falsifying any application or documentation used to acquire registration, certification or licensure;

(6)

issuing a check for any reason to the department which has been returned to the department or its agent for any reason;

(7)

misrepresenting any requirements for certification, recertification, licensure, renewal;

(8)

making a plea of no contest in any criminal action which relates or could relate to the candidate's ability to carry out EMS duties;

(9)

receiving a deferred adjudication in a criminal action which relates or could relate to the candidate's ability to carry out EMS duties; and/or

(10)

staffing an EMS vehicle deemed to be in service while certification or license is expired, suspended or revoked.

(d)

Notification. If the department proposes to deny, suspend, revoke, or probate a certificate or license, the holder of same shall be notified at the address as shown in the current records of the department. The notice must state the alleged facts or conduct to warrant the proposed action and state that the certificant or licensee may request a hearing.

(e)

Hearing request.

(1)

A request for a hearing shall be in writing and submitted to the bureau chief and postmarked within 15 days after the date of the notice. The hearing shall be conducted pursuant to the Administrative Procedure Act, Government Code, Chapter 2001.

(2)

If the applicant, certificant or licensee does not request a hearing in writing within 15 days after notice, the individual is deemed to have waived the opportunity for a hearing and the department may take the proposed action.

(f)

Probation. The department may probate any penalty assessed under this section and may specify terms and conditions of any probation issued. Any revocation of a license or decertification under this section shall require that any future EMS certificate or license issued by the department to the same individual begin with a probationary period of not less than one year.

(g)

Reapplication.

(1)

Two years after denial, decertification or revocation of a license, or the voluntary surrender of a certificate or license while disciplinary action is pending, an individual may petition the department in writing for reapplication for certification or licensure. Expiration of a certificate or license during the suspension period shall not affect the two-year waiting period required before a petition can be submitted.

(2)

The petitioner bears the burden of proving fitness for certification or licensure.

(3)

The department may allow certification or licensure if there is proof that the health, safety, and confidence of the public will be protected.

(4)

The department may deny any petitioner if, in the judgement of the bureau chief, the reason for the original action continues to exist or if the petitioner has failed to offer sufficient proof that there is no longer a threat to public health, safety, and/or confidence.

(5)

If the reapplication is allowed, the petitioner shall be required to meet the requirements for licensure as described in §157.40 of this title (relating to Paramedic Licensure), or certification as described in §157.33 of this title (relating to Certification), §157.43 of this title (relating to Course Coordinator Certification), or §157.44 of this title (relating to Emergency Medical Service Instructor Certification) and in addition shall meet the terms of probation in subsection (f) of this section.

(h)

Surrender of a certificate or license. Surrender of a certificate or license shall not deprive the department of jurisdiction in regard to disciplinary action against the certificant or licensee. An individual who wishes to surrender his or her certification or license prior to the expiration of the certificate or license may do so by:

(1)

completing a Surrender of Certificate or License statement; and

(2)

in the event that a disciplinary action is pending or reasonably imminent, the certificant or licensee must acknowledge that the surrender constitutes a plea of "no contest" to the allegations upon which the disciplinary action is predicated.

(i)

Notification of disposition. A copy of the order of final disposition of proposed disciplinary shall be sent to any licensed EMS provider, first responder organization, medical director, institution or facility with which the certificant or licensee is known to be associated at the address shown in the current records of the department.

§157.37. Certification or Licensure of Persons With Criminal Backgrounds

(a)

Purpose. This section lists guidelines and criteria for establishing the eligibility of persons with criminal backgrounds for certification or continued certification as emergency medical services (EMS) personnel or licensure or continued licensure as paramedics. It is also the purpose of this section to apply the requirements of the Occupations Code, Chapter 53, Subchapter B, and to consider and review the criteria listed in the Occupation Code, Chapter 53, Subchapter B, §53.022 and §53.023. The Texas Department of Health (department) may deny, decertify, revoke, and/or suspend a certificate or license to persons who have committed a felony or misdemeanor to include, but not limited to, those in this section.

(b)

Access to criminal history record information.

(1)

The department is entitled to obtain criminal history information maintained by the Department of Public Safety, the Federal Bureau of Investigation Identification Division, or any other law enforcement agency to investigate the eligibility of a candidate for EMS personnel certification, recertification, licensure or renewal and to investigate the continued eligibility of a certificant/licensee.

(2)

A candidate for EMS certification/licensure or an EMS certificant/licensed paramedic who has disclosed a criminal history record or who has a known criminal history record shall be required to submit a completed set of fingerprints as required under the Government Code, §411.087 and/or §411.110.

(3)

With respect to an applicant for certification or licensure who has a criminal history record, the department is authorized to close an application file when the applicant has failed to respond to request(s) for information for eligibility determination under the Occupations Code, Chapter 53 Subchapter B; Health and Safety Code, Chapter 773; or the rules adopted thereunder within 60 days of said request(s).

(c)

Criminal convictions.

(1)

When the conviction of a felony or misdemeanor relates directly to the duties and responsibilities of EMS personnel, the department may:

(A)

deny to a person the opportunity for eligibility for a certificate or license;

(B)

disqualify a person from receiving a certificate or license; or

(C)

decertify, revoke or suspend an existing certification or license.

(2)

In considering whether a crime relates directly to the occupation of EMS personnel, the department shall consider and review the following:

(A)

the Occupations Code, Chapter 53, Subchapter B, §53.022;

(B)

the nature and seriousness of the crime;

(C)

the relationship of the crime to the purposes for requiring a certificate or license to engage in the occupation;

(D)

the extent to which involvement in EMS would afford a certificant or licensee an opportunity to engage in further criminal activity of the same type as that in which the person previously has been involved; and

(E)

the relationship of the crime to the ability, capacity, or fitness required to perform the duties and discharge the responsibilities of the EMS profession.

(3)

The following crimes are considered to relate to the certification and licensure of EMS personnel because they impact the ability to carry out the duties and responsibilities associated with patient care and public safety and shall be considered and reviewed:

(A)

offenses under the Health and Safety Code, Chapter 773;

(B)

under the Transportation Code;

(C)

offenses under the Alcoholic Beverage Code;

(D)

offenses under the Health and Safety Code, Texas Controlled Substances Act, Chapters 481,482 and 483, relating to substance abuse;

(E)

offenses under Department of Public Safety of the State of Texas, Government Code, Chapter 411, Subchapter H, relating to the license to carry a concealed handgun;

(F)

offenses under the following titles of the Texas Penal Code:

(i)

Title 4 - offenses of attempting or conspiring to commit any of the offenses in this clause;

(ii)

Title 5 - offenses against the person;

(iii)

Title 6 - offenses against the family;

(iv)

Title 7 - offenses against property;

(v)

Title 8 - offenses against public administration;

(vi)

Title 9 - offenses against public order and decency;

(vii)

Title 10 - offenses against public health, safety, and morals; and/or

(viii)

Title 11 - offenses involving organized crime.

(G)

Offenses listed in subparagraph (F)(i)-(viii) of this subsection are not exclusive in that the department may consider similar criminal convictions from other state, federal, foreign or military jurisdictions which, although not listed in paragraph (F)(i)-(viii) indicate the lack of ability, capacity, or fitness of the individual to perform the duties and responsibilities of EMS personnel.

(d)

Criteria for eligibility and continued eligibility. The department will apply the criteria outlined in the Occupations Code, Chapter 53, Subchapter B, §53.023. In applying the criteria, it shall be the responsibility of the candidate/certificant/licensee to obtain and send the department the entire court record for each criminal offense and recommendations of the prosecution, and/or law enforcement and/or correctional authorities regarding the offense(s). The candidate/certificant/licensee shall also furnish documentation acceptable to the department of prior/current employment status, evidence of court-ordered and/or voluntary rehabilitation, evidence of good conduct in their community, and evidence of payment of all outstanding court costs, supervision fees, fines, and restitution as ordered in the criminal cases in which they have been convicted.

(1)

The department believes that those certified/licensed in the EMS profession shall conduct the occupation with honesty, trustworthiness and integrity. The department shall consider, review and take action against those candidates/certificants/licensees who during the course of the criminal history evaluation, or by nature of their conviction of certain crimes, exhibit to the department an inability or unwillingness to follow those requirements.

(2)

As authorized under the Occupations Code, Chapter 53, Subchapter B, §53.021(b), upon a certificant/licensee's felony conviction, felony probation revocation, revocation of parole or revocation of mandatory supervision which results in incarceration, their certificate/license shall be decertified/revoked.

(e)

Procedures for denying, decertifying, revoking, suspending, or probating a certificate or license to persons with criminal backgrounds can be found in §157.36(c)-(k) of this title (relating to Criteria for Denial and Disciplinary Actions for EMS Personnel and Voluntary Surrender of a Certificate or License).

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002573

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.41 - 157.47, 157.51, 157.53

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002576

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.43, 157.44

The new rules are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

§157.43. Course Coordinator Certification

(a)

General.

(1)

A course coordinator is an individual who has the overall responsibility for conducting an emergency medical services (EMS) training course under the direction of an approved EMS training program (program).

(2)

A course coordinator must be certified as at least an emergency medical technician (EMT), and must be certified or licensed at or above the level of the course being coordinated.

(3)

Course coordinator certification is dependent on the individual's EMS personnel certification and is subject to the same status as that personnel certification. If the department imposes disciplinary action in accordance with §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License) or §157.36 of this title (relating to Criteria for Denial and Disciplinary Actions for EMS Personnel and Voluntary Surrender of a Certificate or License), the action shall also be imposed automatically and immediately on the individual's course coordinator certification.

(b)

Levels of certification. Course coordinators may be certified as a basic coordinator or as an advanced coordinator.

(c)

Currently certified course coordinators. Course coordinators certified on the effective date of this rule shall be considered to have met the requirements of subsection (d) or (e) of this section appropriate to their current level of certification.

(d)

Basic coordinator requirements. To be certified as a basic course coordinator, the candidate shall:

(1)

submit an application for basic course coordinator certification along with the nonrefundable fee of $75 to the Texas Department of Health (department) except a fee shall not be required if compensation is not received for coordinating training courses or programs;

(2)

have been a certified EMS instructor for at least two consecutive years;

(3)

have documented not less than 120 hours of instruction for initial EMS certificants; or have successfully conducted an EMT-Basic course;

(4)

submit documentation of positive evaluations as a certified instructor.

(5)

be affiliated with and operate under the supervision of a licensed provider, an EMS medical director, a teaching hospital, a regionally accredited post-secondary educational institution and/or a health care institution accredited by an organization recognized by the department;

(6)

submit letters of intent from qualified providers of clinical and field internship experience;

(7)

have successfully completed a department-sponsored course coordinator training course; and

(8)

after completing all the above requirements, pass the EMS coordinator exam and retest, if necessary, no later than one year after course completion date. The nonrefundable retest fee is $25, except a fee shall not be required if compensation is not received for coordinating training courses or programs. If requirements are not completed within one year after course completion date, the candidate must meet the requirements of subsection (d) of this section including the completion of another initial course to be certified.

(e)

Advanced coordinator requirements. To be certified as an advanced course coordinator, the candidate shall:

(1)

submit an application for advanced course coordinator certification along with the nonrefundable fee of $75 to the department; except a fee shall not be required if compensation is not received for coordinating training courses or programs;

(2)

have an associate degree, a bachelor degree, or an advanced degree;

(3)

have been a certified EMS instructor for at least four consecutive years or as a basic course coordinator for two consecutive years;

(4)

have documented not less than 120 hours of instruction for initial EMS certificants;

(5)

submit documentation of positive evaluations as a certified instructor or as a basic coordinator;

(6)

be affiliated with and operate under the supervision of a regionally accredited post-secondary educational institution, a health care institution accredited by an organization recognized by the department, or another entity approved by the department to sponsor an advanced training program in accordance with §157.32 of this title (relating to EMS Education Program and Course Approval);

(7)

submit a letter of intent from qualified providers of clinical and field internship experience;

(8)

have successfully completed a department-sponsored course coordinator training course;

(9)

after completing all the above requirements, pass the EMS coordinator exam and retest, if necessary, no later than one year after course completion date. The nonrefundable retest fee is $25, except a fee shall not be required if compensation is not received for coordinating training courses or programs. If requirements are not completed within one year after course completion date, the candidate must meet the requirements of subsection (e) of this section including the completion of another initial course to be certified; and

(10)

candidates who hold current basic coordinator certification and are applying for advanced coordinator certification must complete all requirements of this subsection except paragraphs (e)(8) and (e)(9) of this subsection.

(f)

Period of Certification. After verification by the department of the information submitted by the candidate, the candidate who meets the requirements of the applicable subsection (d) or (e) of this section shall be certified as an course coordinator for two years commencing on the date of issuance of the certificate.

(g)

Course coordinator training. All course coordinator courses shall be conducted by the department or by the department in conjunction with a regionally accredited post-secondary educational institution approved by the department to sponsor a training program. Criteria for admission to coordinator training shall be as follows:

(1)

the candidate for admission to course coordinator training will meet the requirements of subsection (d) or (e) of this section as appropriate to the level of certification desired;

(2)

the candidate shall submit a resume and completed application to the appropriate department regional EMS office;

(3)

the appropriate department regional EMS director will forward the application and attachments to the appropriate training facility with a recommendation regarding the candidate's admission status; and

(4)

successful candidates will be given a seat in the class based on availability and admissions requirements. .

(h)

Responsibilities. Course coordinator shall have the following responsibilities:

(1)

plan for and evaluate the overall operation of assigned courses;

(2)

provide supervision and oversight for assigned courses;

(3)

act as liaison between the students, personnel instructing in assigned courses, the program, and the department;

(4)

coordinate submission of course approval documents and fees, if applicable, for assigned courses to the department as defined in the Education and Training Manual;

(5)

assure availability of classrooms and other facilities necessary to provide for the instruction and convenience of students enrolled in assigned courses;

(6)

in cooperation with the training program, process student applications and select students;

(7)

schedule classes and assign program instructors;

(8)

assure that training equipment and supplies are available and operational for each laboratory session;

(9)

maintain effective relationships with clinical and field internships facilities necessary to meeting the instructional objectives of assigned courses;

(10)

develop field internship and clinical objectives for assigned courses;

(11)

train and evaluate internship preceptors;

(12)

in cooperation with the training program, maintain all course records for a minimum of five years;

(13)

in cooperation with the training program coordinate course written examinations, skills proficiency verifications, and other student evaluations;

(14)

in cooperation with the training program evaluate the effectiveness of the personnel who instruct in assigned courses;

(15)

in cooperation with the training program supervise and evaluate the effectiveness of the clinical and field internship training for assigned courses; and

(16)

in cooperation with the training program attest to the successful course completion of all students who meet the program's requirements for completion.

(i)

Exception. A program may request the department to grant an exception to allow a person not currently certified as a course coordinator to temporarily perform the duties listed in subsection (h) of this section.

(1)

Such request must be submitted in writing and must include the following:

(A)

documentation of the urgency of the situation;

(B)

a letter from the program endorsing the individual who is to temporarily perform the duties of course coordinator; and

(C)

letters of intent from qualified providers of clinical and field internship experiences appropriate to the level of training to be offered; and

(D)

a letter of intent from a medical director.

(2)

In determining whether the request for an exception is to be approved or denied, the department shall consider but not be limited to the following issues:

(A)

resignation of a previous course coordinator or the inability of a course coordinator to complete a current training course;

(B)

need for training in an area where a certified course coordinator is not available within a reasonable distance and training is unavailable through no outreach or distance learning technology; and

(C)

the probable adverse consequences to prehospital emergency care. if the exception is not approved.

(3)

After evaluation by the department, the program shall be notified, in writing, of the approval or denial of the request.

(4)

An individual who is approved shall be considered a temporary course coordinator for not more than two years . If all requirements for course coordinator certification are not met in the two-year period, the approved training program with which the coordinator is affiliated must demonstrate a continuing need for the exception. If the department does not continue the exception, temporary status shall cease and the individual may no longer function as a temporary course coordinator.

(j)

Recertification.

(1)

Prior to the expiration of a course coordinator certificate, the department shall send a notice of expiration to the certificant at the address shown in the current records of the department. It is the responsibility of course coordinators to notify the department of any change of address.

(2)

If a certificant has not received notice of expiration from the department 30 days prior to the expiration, it is the duty of the certificant to notify the department and request an application for recertification. Failure to apply for recertification shall result in expiration of the certificate.

(3)

To be eligible for recertification, the course coordinator shall meet recertification requirements during the latest coordinator certification period and:

(A)

maintain active EMS certification as required in subsection (a)(2) of this section;

(B)

attend regional updates for course coordinator as required by the department;

(C)

maintain association with:

(i)

an approved basic or advanced program if recertifying as a basic coordinator;

(ii)

an approved advanced program if recertifying as an advanced coordinator;

(D)

maintain affiliation with entities which provide clinical and field internship experience;

(E)

submit an application for recertification and a nonrefundable fee as in subsection (d) or (e) of this section;

(4)

After verification by the department of the information submitted the course coordinator who meets the requirements of subsection (d) or (e) of this section shall be recertified for two years commencing on the date following the expiration of the last certificate.

(k)

Late recertification.

(1)

An application for recertification shall be considered late if the application and nonrefundable fee are received after the most recent certificate has expired and if all requirements for recertification are not met prior to the end of the most recent certification period.

(2)

A course coordinator who has not recertified prior to the end of his most recent certification period is not certified and may not perform the duties of a course coordinator.

(l)

To be eligible for recertification, the candidate shall meet the following:

(1)

A candidate whose certificate has been expired for 90 days or less may renew the certificate by submitting an application and paying a nonrefundable renewal fee that is equal to 1-1/2 times the normally required application renewal fee for that level as listed in subsections (d) or (e) of this section.

(2)

A candidate whose certificate has been expired for more than 90 days but less than one year may renew the certificate by submitting an application and paying a nonrefundable renewal fee that is equal to two times the normally required application renewal fee as listed in subsections (d) or (e) of this section.

(3)

A candidate must complete of all requirements for recertification no later than one year after the expiration of the most recent certificate.

(4)

After verification by the department of the information submitted by the candidate, the candidate who meets the requirements of this subsection shall be recertified for two years commencing on the day of issuance of a certificate.

(5)

A candidate whose certification is expired more than one year must meet the requirements of subsection (d) or (e) of this section including the completion of another initial course to be certified.

(m)

Disciplinary actions.

(1)

Administrative penalty. The department may impose an administrative penalty on a course coordinator not to exceed $1,000 per day per violation of the Health and Safety Code or the rules adopted thereunder.

(2)

Emergency suspension. The bureau chief of the Bureau of Emergency Management (bureau) may issue an emergency order to suspend an course coordinator's certification if the bureau chief, has reasonable cause to believe continued activity by the individual constitutes a threat to the public health and safety.

(A)

An emergency suspension shall be effective immediately without a hearing or notice to the certificate holder. Notice shall be established on the date that a copy of the signed emergency suspension order is sent to the address shown in the current records of the department. Notice shall also be given to any sponsoring entity.

(B)

If a written request for a hearing is received from the certificate holder within 15 days of the suspension, the department shall conduct a hearing not later than the 30th day after the date on which a hearing request is received to determine if the emergency suspension is to be continued, modified, or rescinded. The hearing and appeal from any disciplinary action related to the hearing shall be governed by the Administrative Procedure Act, Government Code, Chapter 2001.

(3)

Suspension or revocation. The department may suspend or revoke a certificate it has issued to an EMS coordinator. A course coordinator's certification may be suspended or revoked for, but not limited to the following:

(A)

failing to maintain active status EMS personnel certification at the appropriate level;

(B)

failing to comply with the responsibilities of a course coordinator as defined in subsection (h) of this section;

(C)

falsifying an application for EMS certification or licensure;

(D)

falsifying a program approval application, a self-study, a course approval application, or any supporting documentation;

(E)

falsifying a course completion certificate or any other document that records or verifies course activity and/or is a part of the course record;

(F)

assisting another to obtain or to attempt to obtain personnel certification or recertification by fraud, forgery, deception, or misrepresentation;

(G)

failing to complete and submit the course applications and student documents within established time frames;

(H)

coordinating or attempting to coordinate a course above the coordinator's level of certification;

(I)

compromising or failing to maintain the order, discipline and fairness of a department-approved course or program;

(J)

allowing inadequate class presentations in a course for which the coordinator is responsible;

(K)

demonstrating a lack of supervision of personnel instructing in courses for which the coordinator is responsible;

(L)

compromising an examination or examination process administered or approved by the department;

(M)

cheating or assisting another in cheating on an EMS examination, other evaluation or any other activity offered or conducted by the department, a training program approved by the department, or a provider licensed by the department;

(N)

accepting any benefit to which there is no entitlement or benefits in any manner through fraud, deception, falsification, misrepresentation, theft, misappropriation, or coercion;

(O)

failing to maintain appropriate policies, procedures and safeguards to ensure the safety of students, instructors or other class participants;

(P)

allowing recurrent use of inadequate, inoperable, or malfunctioning equipment;

(Q)

failing to maintain the fiscal integrity of a course for which the coordinator is responsible;

(R)

issuing a check to the department which is returned unpaid;

(S)

failing to maintain education course records;

(T)

demonstrating unwillingness or inability to comply with the Health and Safety Code and/or the rules adopted thereunder;

(U)

failing to give the department true and complete information when asked regarding any alleged or actual violation of the Health and Safety Code, or the rules adopted thereunder, or failing to report a violation;

(V)

functioning or attempting to function as a course coordinator during a period of suspension which may be cause for suspension of the coordinator certification; and/or

(W)

committing any violation during a probationary period.

(4)

Notification. If the department proposes to suspend or revoke a course coordinator's certificate, the course coordinator shall be notified at the address shown in the current records of the department. The notice must state the alleged facts or conduct warranting the action and state that the course coordinator has an opportunity to request a hearing in accordance with the Administrative Procedure Act, Government Code, Chapter 2001.

(A)

The course coordinator may request a hearing within 15 days after the date of the notice. This request shall be in writing and submitted to the bureau chief.

(B)

If the course coordinator does not request a hearing within 15 days after the date of the notice of opportunity, the course coordinator waives the opportunity for a hearing and the department shall implement its proposal.

(5)

Probation. The department may probate any penalty assessed under this section and may specify terms and conditions of any probation issued.

(6)

Reapplication.

(A)

Two years after the revocation of a certificate, an individual may petition the department, in writing, for the opportunity to reapply for certification.

(B)

The department shall evaluate the petition and may allow or deny the opportunity to reapply for certification.

(C)

in evaluating a petition for permission to reapply for certification the department shall consider but is not limited to the following issues:

(i)

the likelihood of a repeat of the actions or inactions that led to revocation;

(ii)

the petitioners overall record as a course coordinator;

(iii)

letters of support or recommendation;

(iv)

letters of protest or nonsupport of the petition; and

(v)

the need for the services of a course coordinator in the given area the course coordinator would serve.

(D)

The petitioner shall be notified of the department's decision to allow or deny the submission of reapplication for certification within 60 days of the submission of the request.

(E)

A course coordinator whose certificate expires during a suspension or revocation period may not petition to reapply for certification until the end of the suspension or revocation period.

§157.44. Emergency Medical Service Instructor Certification.

(a)

General.

(1)

A certified emergency medical service (EMS) instructor is an individual who has received training approved by the Texas Department of Health (department) to conduct the classroom or laboratory portion of an EMS training course.

(2)

An instructor must be currently certified as at least an emergency medical technician (EMT) and may not instruct knowledge or skills above his current level of certification.

(3)

Instructor certification is dependent on the individual's EMS personnel certification and is subject to the same status as that personnel certification. If the department imposes disciplinary action in accordance with §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License) or §157.36 of this title (relating to Criteria for Denial and Disciplinary Actions for EMS Personnel and Voluntary Surrender of a Certificate or License), the action shall also be imposed automatically and immediately on the individual's instructor's certification.

(b)

Certification. To obtain certification, a candidate shall:

(1)

have a high school diploma or a general educational development (GED) certificate;

(2)

have active EMS personnel certification;

(3)

complete a training program using an instructor training curriculum approved by the department;

(4)

submit an application to the department with a nonrefundable fee of $50 to the department, except a fee shall not be required if compensation is not received for instructing training courses or programs; and a course completion document from a department-approved instructor course; and

(5)

pass the instructor examination conducted by the department.

(c)

Currently certified instructors shall be considered to have met the qualifications in this section.

(d)

Period of certification. After verification by the department of the information submitted by the candidate, the candidate who meets the requirements of subsection (b) of this section shall be certified as an instructor for two years commencing on the date of issuance of the certificate.

(e)

Responsibilities. An instructor shall have the following responsibilities:

(1)

conducting classroom and laboratory sessions in accordance with lesson objectives as assigned by the course coordinator;

(2)

conducting skills proficiency verifications and other student evaluations as assigned by the course coordinator;

(3)

assisting the course coordinator in preparing and maintaining records and performing other duties necessary to insure the integrity, efficiency and effectiveness of the course.

(f)

Recertification.

(1)

Prior to the expiration of a certificate, the department shall send a notice of expiration to the certificant at the address shown in the current records of the department. It is the responsibility of EMS personnel to notify the department of any change of address.

(2)

If a certificant has not received notice of expiration from the department 30 days prior to the expiration, the certificant shall request an application for recertification from the department or download an application from the Internet. Failure to apply for recertification shall result in expiration of the certificate.

(3)

To be eligible for recertification, the instructor shall meet recertification requirements during the latest instructor certification period:

(A)

maintain active status EMS certification; and

(B)

submit the application for recertification and a nonrefundable fee of $50.

(4)

After verification by the department of the information submitted, the candidate who meets the requirements of this section shall be recertified for two years commencing on the day following the expiration of the current certificate.

(g)

Late recertification.

(1)

An application for renewal of a certificate shall be considered late if:

(A)

the application and nonrefundable fee are received after the most recent certificate has expired or;

(B)

all requirements for recertification are not met prior to the end of the most recent certification period.

(2)

An instructor who has not recertified prior to the end of his most recent certification period is not certified.

(h)

Recertification. To be eligible for recertification, the candidate shall meet the following:

(1)

A candidate whose certificate has been expired for 90 days or less may renew the certificate by submitting an application and paying a nonrefundable renewal fee that is equal to 1-1/2 times the normally required application renewal fee for that level as listed in subsection (b)(4) of this section;

(2)

A candidate whose certificate has been expired for more than 90 days but less than one year may renew the certificate by submitting an application and paying a nonrefundable renewal fee that is equal to two times the normally required application renewal fee as listed in subsection (b)(4) of this section.

(3)

A candidate must complete all the requirements for recertification no later than one year after the expiration of the most recent certificate.

(4)

After verification by the department of the information submitted by the candidate, the candidate who meets the requirements of this subsection shall be recertified for two years commencing on the day of issuance of a certificate.

(5)

A candidate whose certification is expired more than one year must meet the requirements of subsection (b) of this section including the completion of another initial course to be certified.

(i)

Disciplinary action.

(1)

Emergency suspension. The bureau chief of the Bureau of Emergency Management may issue an emergency order to suspend an instructor if the bureau chief has reasonable cause to believe continued activity of the individual constitutes a threat to the public health or safety.

(A)

An emergency suspension shall be effective immediately without a hearing or written notice to the certificate holder. Notice to the certificant shall be established on the date that a copy of the signed emergency suspension order is sent to the address shown in the current records of the department, or by return receipt. Notice shall also be sent to any sponsoring entity.

(B)

If a written request for a hearing is received from the certificate holder within 15 days of the date of notice, the department shall conduct a hearing not later than the 30th day after the date on which a hearing request is received to determine if the emergency suspension is to be continued, modified, or rescinded. The hearing and appeal from a disciplinary action related to the hearing shall be in accordance with the Administrative Procedure Act, Government Code, Chapter 2001.

(2)

Suspension or revocation. An instructor's certification may be suspended or revoked for, but not limited to, the following reasons:

(A)

failing to maintain active status EMS personnel certification at the appropriate level;

(B)

failing to comply with the responsibilities of an instructor as in subsection (e) of this section;

(C)

falsifying an application for EMS certification;

(D)

falsifying a program approval application, a self-study, a course approval application, or any supporting documentation;

(E)

falsifying a course completion certificate or any other document that records or verifies course activity and/or is a part of the course record;

(F)

compromising department or program standards for verification of skills proficiency or falsifying proficiency verification records;

(G)

assisting another to obtain or to attempt to obtain personnel certification or recertification by fraud, forgery, deception or misrepresentation;

(H)

failing to complete and submit student documents within the established time frames;

(I)

compromising or failing to maintain the order, discipline and fairness of a department-approved course or program;

(J)

delivering or allowing inadequate class presentations;

(K)

compromising an examination or examination process administered or approved by the department;

(L)

cheating or assisting another in cheating on an EMS examination, other evaluation or any other activity offered or conducted by the department, a training program approved by the department, or a provider licensed by the department;

(M)

accepting any benefit to which there is no entitlement or benefits in any manner through fraud, deception, falsification, misrepresentation, theft, misappropriation or coercion;

(N)

failing to maintain appropriate policies, procedures and safeguards to ensure the safety of students, fellow instructors or other class participants;

(O)

allowing recurrent use of inadequate, inoperable, or malfunctioning equipment;

(P)

issuing a check to the department which is returned unpaid;

(Q)

failing to maintain education course records for initial or continuing education (CE) courses;

(R)

demonstrating an unwillingness or inability to comply with the Health and Safety Code and rules adopted thereunder;

(S)

failing to give the department true and complete information when asked regarding any alleged or actual violation of the Health and Safety Code, or the rules adopted thereunder, or failing to report a violation;

(T)

committing any violation during a probationary period; and

(U)

functioning or attempting to function as an instructor during a period of suspension shall be cause for revocation of the instructor certification.

(3)

Notification. If the department proposes to take disciplinary action against an EMS instructor, the certificant shall be notified at the address shown in the current records of the department. The notice must state the alleged facts or conduct warranting the action and state that the certificant has an opportunity to request a hearing.

(A)

The certificant may request a hearing within 15 days after the date of the notice. This request shall be in writing and submitted to the bureau chief. The hearing shall be conducted pursuant to the Administrative Procedure Act, Government Code, Chapter 2001.

(B)

If the certificant does not request a hearing, after being sent the notice of opportunity, the certificant waives the opportunity for a hearing and the department shall implement its proposal.

(4)

Probation. The department may probate any penalty assessed under this section and may specify terms and conditions of any probation issued.

(5)

Reapplication.

(A)

Two years after the revocation of an instructor certification an individual may petition the department, in writing, for the opportunity to reapply for certification.

(B)

The department shall evaluate the petition and may allow or deny the opportunity to submit an application for recertification.

(C)

In evaluating a petition for permission to reapply for certification the department shall consider, but is not limited to, the following issues:

(i)

the likelihood of a repeat of the actions or inactions that led to revocation;

(ii)

the petitioners overall record as an instructor;

(iii)

letters of support or recommendation;

(iv)

letters in protest or nonsupport of the petition; and

(v)

the need for the services of an instructor in a given area.

(D)

The petitioner shall be notified of the department's decision to allow or deny the submission of reapplication within 60 days of the request.

(E)

An instructor whose certificate expires during a suspension or revocation period may not petition to reapply for certification until the end of the suspension or revocation period.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002575

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.61 - 167.64

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002577

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §157.101

The repeal is adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002578

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.121 - 157.128

The repeals are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002579

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236

25 TAC §§157.122, 157.123, 157.125, 157.128

The new rules are adopted under the Health and Safety Code, Chapter 773, which provides the Board of Health (board) with the authority to adopt rules to implement the Emergency Medical Services Act; and §12.001, which provides the board with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health.

§157.122. Trauma Service Areas.

(a)

Trauma service areas (TSAs) are established for descriptive and planning purposes and not for the purpose of restricting patient referral.

(b)

The state has been geographically divided by counties into 22 TSAs; however:

(1)

counties may request the bureau of emergency management (bureau) to re-align them to another TSA per the process in subsection (d) of this section;

(2)

each TSA shall have at least a lead general trauma facility within its boundaries by December 31, 2000, or the bureau may re-align the counties in that TSA to other TSAs which have such a facility;

(3)

each TSA shall be multi-county with no fewer than three Texas counties; and

(4)

a TSA may include areas from other states or countries.

(c)

The counties included in the 22 TSAs are grouped as follows (updated lists will be maintained by the bureau):

(1)

Area A - Armstrong, Briscoe, Carson, Childress, Collingsworth, Dallam, Deaf Smith, Donley, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Lipscomb, Moore, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher, Wheeler;

(2)

Area B - Bailey, Borden, Castro, Cochran, Cottle, Crosby, Dawson, Dickens, Floyd, Gaines, Garza, Hale, Hockley, Kent, King, Lamb, Lubbock, Lynn, Mitchell, Motley, Scurry, Terry, Yoakum;

(3)

Area C - Archer, Baylor, Clay, Foard, Hardeman, Jack, Montague, Wichita, Wilbarger, Young;

(4)

Area D - Brown, Callahan, Coleman, Comanche, Eastland, Fisher, Haskell, Jones, Knox, Nolan, Shackelford, Stephens, Stonewall, Taylor, Throckmorton;

(5)

Area E - Collin, Cooke, Dallas, Denton, Ellis, Erath, Fannin, Grayson, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Tarrant, Wise;

(6)

Area F - Bowie, Cass, Delta, Hopkins, Lamar, Morris, Red River, Titus;

(7)

Area G - Anderson, Camp, Cherokee, Franklin, Freestone, Gregg, Harrison, Henderson, Houston, Marion, Panola, Raines, Rusk, Shelby, Smith, Trinity, Upshur, Van Zandt, Wood;

(8)

Area H - Angelina, Nacogdoches, Polk, Sabine, San Augustine, San Jacinto, Tyler;

(9)

Area I - Culberson, El Paso, Hudspeth;

(10)

Area J - Andrews, Brewster, Crane, Ector, Glasscock, Howard, Jeff Davis, Loving, Martin, Midland, Pecos, Presidio, Reeves, Terrell, Upton, Ward, Winkler;

(11)

Area K - Coke, Concho, Crockett, Irion, Kimble, Mason, McCulloch, Menard, Reagan, Runnels, Schleicher, Sterling, Sutton, Tom Green;

(12)

Area L - Bell, Coryell, Falls, Hamilton, Lampasas, Milam, Mills;

(13)

Area M - Bosque, Hill, Limestone, McLennan;

(14)

Area N - Brazos, Burleson, Grimes, Leon, Madison, Robertson, Washington;

(15)

Area O - Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, San Saba, Travis, Williamson;

(16)

Area P - Atascosa, Bandera, Bexar, Comal, Dimmit, Edwards, Frio, Gillespie, Gonzales, Guadalupe, Karnes, Kendall, Kerr, Kinney, La Salle, Maverick, Medina, Real, Uvalde, Val Verde, Wilson, Zavala;

(17)

Area Q - Austin, Colorado, Fort Bend, Harris, Matagorda, Montgomery, Walker, Waller, Wharton;

(18)

Area R - Brazoria, Chambers, Galveston, Hardin, Jasper, Jefferson, Liberty, Newton, Orange;

(19)

Area S - Calhoun, Dewitt, Goliad, Jackson, Lavaca, Victoria;

(20)

Area T - Jim Hogg, Webb, Zapata;

(21)

Area U - Aransas, Bee, Brooks, Duval, Jim Wells, Kenedy, Kleberg, Live Oak, McMullen, Nueces, Refugio, San Patricio; and

(22)

Area V - Cameron, Hidalgo, Starr, Willacy.

(d)

The realignment of a county may be initiated by the bureau or at the request of either the county government, a licensed health care facility, or a licensed emergency medical services (EMS) provider in that county.

(1)

The requesting entity should forward correspondence to the bureau specifying:

(A)

reason(s) for realignment request;

(B)

existing patient routing patterns used by both EMS providers and health care facilities, including distances and transport times involved in this patient routing;

(C)

all entities included in the request and a listing of all other licensed health care facilities and licensed EMS providers in the county; and

(D)

documentation that the receiving regional advisory council (RAC) is amenable to the re-alignment.

(2)

Copies of the correspondence should be forwarded by the requesting party to all impacted RACs, county governments, licensed health care facilities/EMS providers in the county, and the appropriate Texas Department of Health regional EMS office.

(3)

The bureau will evaluate the request based on the impact to patient care and will notify all parties of the decision.

§157.123. Regional Emergency Medical Services/Trauma Systems

(a)

The bureau of emergency management (bureau) shall recognize the establishment of a regional emergency medical services (EMS)/trauma system (system) within a trauma service area (TSA) as described in §157.122 of this title (relating to Trauma Service Areas).

(b)

Establishment of a regional EMS/trauma system consists of three phases.

(1)

The first phase begins with the establishment of a regional advisory council (RAC) and ends with recognition of the RAC by the bureau.

(A)

All health care entities who care for trauma patients should be offered membership on the RAC.

(B)

The bureau shall recognize only one official RAC for a TSA.

(C)

At least quarterly, a RAC shall submit evidence of on-going activity, such as meeting notices and minutes, to the bureau.

(D)

Annually, the RAC shall file a report with the bureau which describes progress toward system development, demonstrates on-going activity, and includes evidence that members of the RAC are currently involved in trauma care.

(E)

The RAC functions without the expectation of comprehensive, permanent and/or unrestricted state funding.

(F)

RACs may request technical assistance from the bureau at any time.

(2)

The second phase begins with RAC recognition by the bureau and ends with approval of a complete EMS/trauma system plan (plan) by the bureau.

(A)

The RAC shall develop a system plan based on standard guidelines for comprehensive system development. The system plan is subject to approval by the bureau.

(B)

The bureau shall review the plan to assure that:

(i)

all counties within the TSA have been included unless a specific county, or portion thereof, has been aligned within an adjacent system;

(ii)

all health care entities and interested specialty centers have been given an opportunity to participate in the planning process; and

(iii)

the following components have been addressed:

(I)

injury prevention;

(II)

access to the system;

(III)

communications;

(IV)

medical oversight;

(V)

prehospital triage criteria;

(VI)

diversion policies;

(VII)

bypass protocols;

(VIII)

regional medical control;

(IX)

regional trauma treatment protocols;

(X)

facility triage criteria;

(XI)

inter-hospital transfers;

(XII)

planning for the designation of trauma facilities, including the identification of the lead facility(ies); and

(XIII)

a performance improvement program that evaluates processes and outcomes from a system perspective.

(C)

Bureau approval of the completed plan may qualify health care entities participating in the system to receive state funding for trauma care if funding is available.

(3)

The third phase begins with approval of a complete plan by the bureau and ends with the regional EMS/trauma system being recognized by the bureau.

(A)

Upon approval, a RAC implements the plan to include:

(i)

education of all entities about the plan components;

(ii)

on-going review of resource, process, and outcome data; and

(iii)

if necessary, revision and re-approval of the plan or plan components by the bureau.

(B)

At any time following implementation of the plan, a RAC may request recognition as a regional EMS/trauma system which will include:

(i)

an on-site review by a team composed of bureau staff and trained non-Texas Department of Health surveyors;

(ii)

bureau evaluation of a report developed following the on-site review; and

(iii)

notification of the RAC by the bureau of the results of the review.

§157.125. Requirements for Trauma Facility Designation.

(a)

The Bureau of Emergency Management (bureau) shall recommend to the commissioner of health (commissioner) the designation of trauma facilities as follows:

(1)

Comprehensive (Level I) trauma facility designation, if the applicant hospital meets or exceeds the current American College of Surgeons (ACS) essential criteria for a verified Level I trauma center, actively participates on the appropriate regional advisory council (RAC), and submits data to the state trauma registry;

(2)

Major (Level II) trauma facility designation, if the applicant hospital meets or exceeds the current ACS essential criteria for a verified Level II trauma center, actively participates on the appropriate RAC, and submits data to the state trauma registry;

(3)

General (Level III) trauma facility designation, if the hospital meets or exceeds the Texas General Trauma Facility Criteria; and

(4)

Basic (Level IV) trauma facility designation, if the hospital meets or exceeds the Texas Basic Trauma Facility Criteria.

(b)

The designation process shall consist of three phases.

(1)

The first phase is the application phase which begins with completing and submitting to the bureau an application and nonrefundable fee for designation as a trauma facility and ends when the bureau approves a site survey (survey);

(2)

The second phase is the review phase which begins with the survey and ends with a bureau recommendation to the commissioner to designate the hospital;

(3)

The third phase is the final phase which begins with the commissioner reviewing the recommendation and ends with his/her final decision. This phase also includes an appeal procedure for the denial of a designation application in accordance with the Administrative Procedure Act, Government Code, Chapter 2001.

(c)

The bureau's analysis of submitted application materials, which may result in recommendations for corrective action when deficiencies are noted, shall include a review of:

(1)

the evidence of participation in system planning;

(2)

the completeness and appropriateness of the application materials submitted, including the non-refundable application fee as follows:

(A)

for comprehensive and major trauma facility applicants, the fee will be no more than $3.00 per licensed bed with an upper limit of $3000 and a lower limit of $100;

(B)

for general trauma facility applicants, the fee will be no more than $2.00 per licensed bed with an upper limit of $2000 and a lower limit of $100; and

(C)

for basic trauma facility applicants, the fee will be no more than $1.00 per licensed bed with an upper limit of $1000 and a lower limit of $100.

(d)

When the application phase results in a bureau approval for a survey, the bureau shall notify the hospital to contract for the survey, as follows.

(1)

Level I and II applicants shall request a survey through the ACS verification program.

(2)

Level III and IV applicants may request a survey through the ACS verification program or by a team of approved non- Texas Department of Health (department) surveyors.

(3)

The applicant shall notify the bureau of the date of the planned survey and the composition of the survey team.

(4)

The applicant shall be responsible for any expenses associated with the survey.

(5)

The bureau at its discretion may appoint an observer to accompany the survey team. In this event, the cost for the observer shall be borne by the bureau. A hospital shall have the right to refuse to allow non-department observers to participate in a survey.

(6)

The survey shall be completed within one year of the date of the approval of the application.

(7)

At any time a hospital may file a complaint with the bureau regarding the conduct of a surveyor. The bureau will investigate the complaint and notify the hospital of the outcome.

(e)

The survey team composition shall be as follows.

(1)

A survey team for a Level I, Level II, or lead Level III trauma facility applicant, shall be multi-disciplinary and include at a minimum: two general surgeons, an emergency physician, and a trauma nurse all active in the management of trauma patients.

(2)

Other Level III trauma facility applicants shall be surveyed by a survey team consisting of a trauma nurse and surgeon active in the management of trauma patients.

(3)

Level IV Trauma facility applicants shall be surveyed by a department representative, registered nurse or licensed physician. A second surveyor may be requested by the hospital or the department.

(4)

Non-department surveyors must meet the following criteria:

(A)

have at least three years experience in the care of trauma patients;

(B)

be currently employed in the coordination of care for trauma patients;

(C)

have direct experience in the preparation for and successful completion of trauma facility verification/designation;

(D)

have successfully completed the department Trauma Facility Site Surveyor Course;

(E)

have current credentials as follows:

(i)

Trauma Nurse Core Curriculum for nurses; or

(ii)

Advanced Trauma Life Support for physicians; and

(F)

have successfully completed a site survey internship.

(5)

All members of the survey team, except department staff, should come from a public health region and/or RAC outside the hospital's location and at least 100 miles from the applicant hospital. There shall be no business or patient care relationship between the surveyor and/or the surveyor's place of employment and the hospital being surveyed.

(f)

When an applicant hospital is notified of the survey team composition, it has 30 days from the date of the letter to alert the bureau of potential conflict of interest concerns.

(g)

The survey team shall evaluate the hospital's compliance with the designation criteria, by:

(1)

reviewing medical records, staff rosters and schedules, performance improvement committee meeting minutes and other documents specifically relevant to trauma care;

(2)

reviewing equipment and the physical plant; and

(3)

conducting interviews with hospital personnel.

(h)

Findings of the survey team shall be forwarded to the hospital within 30 calendar days of the date of the survey. If a hospital wants to continue the designation process, the complete survey report, including patient care reviews, must be submitted to the bureau within six months of the date of the survey or the application will expire.

(1)

The bureau shall review the findings for compliance with the criteria. If a hospital does not meet the criteria for the level of designation for which it applied, the bureau shall notify the hospital of the requirements it must meet to achieve designation at the appropriate level.

(2)

A recommendation for designation shall be made to the commissioner based on compliance with the criteria.

(3)

In the event there is a problem area in which a hospital does not comply with the criteria, the bureau shall notify the hospital of deficiencies and recommend corrective action.

(A)

The hospital shall submit a report to the bureau which outlines the corrective action taken. The bureau may require a second survey to insure compliance with the criteria. If the hospital and/or bureau report substantiates action that brings the hospital into compliance with the criteria, the bureau shall recommend designation to the commissioner.

(B)

If a hospital disagrees with a bureau decision regarding its designation application or status, it may request a secondary review by the designation review committee. Membership on the designation review committee will:

(i)

be voluntary;

(ii)

be appointed by the bureau chief;

(iii)

be representative of trauma care providers and all levels of designated trauma facilities; and

(iv)

include representation from the department and the Trauma Subcommittee of the statewide emergency systems advisory committee.

(C)

If the designation review committee disagrees with the bureau recommendation for corrective action, the records shall be referred to the associate commissioner for health care quality and standards for recommendation to the commissioner.

(i)

The bureau shall provide a copy of the survey report, for surveys conducted by or contracted for by the department, and results to the applicant hospital.

(j)

At the end of the secondary review and final phases of the designation process, if a hospital disagrees with the bureau recommendations, opportunity for an appeal in accordance with the Administrative Procedure Act, Government Code, Chapter 2001 shall be offered.

(k)

The bureau may grant an exception to this section if it finds that compliance with this section would not be in the best interests of the persons served in the affected local system.

(l)

The applicant hospital shall have the right to withdraw its application at any time prior to being awarded trauma facility designation by the bureau.

(m)

If the commissioner concurs with the recommendation to designate, the hospital shall receive a letter of designation for three years. Additional actions, such as a site review or submission of information, to maintain designation may be required by the department.

(n)

It shall be necessary to repeat the designation process as described in this section prior to expiration of a facility's designation or the designation will be considered expired.

(o)

A designated trauma facility shall:

(1)

notify the bureau and RAC the within five days if temporarily unable to comply with designation standards;

(2)

notify the bureau and the RAC if it chooses to no longer provide trauma services commensurate with its designation level, as follows.

(A)

If the trauma facility chooses to apply for a lower level of designation, it may do so at any time; however, it shall be necessary to repeat the designation process as described in subsections (b) - (c) of this section. There shall be a paper review by the bureau to determine if a full survey shall be required.

(B)

If the trauma facility chooses to permanently relinquish its designation, it shall provide at least 30 days notice to the RAC and the bureau.

(3)

comply with the provisions within these sections, all current state and system standards as described in this chapter, and all policies, protocols, and procedures as set forth in the system plan;

(4)

continue its commitment to provide the resources, personnel, equipment, and response as required by its designation level; and

(5)

participate in the state trauma registry.

(p)

A health care facility may not use the terms "trauma facility", "trauma hospital", "trauma center", or similar terminology in its signs or advertisements or in the printed materials and information it provides to the public unless the health care facility has been designated as a trauma facility according to the process described in this section. This subsection also applies to hospitals whose designation has lapsed.

(q)

A trauma facility shall not advertise or publicly assert in any manner that its trauma facility designation affects its care capabilities for non-trauma patients or that its trauma facility designation should influence the referral of non-trauma patients.

(r)

The bureau shall have the right to review, inspect, evaluate, and audit all trauma patient records, trauma performance improvement committee minutes, and other documents relevant to trauma care in any designated trauma facility at any time to verify compliance with the statute and these rules, including the designation criteria. The bureau shall maintain confidentiality of such records to the extent authorized by the Government Code, Chapter 552, Public Information. Such inspections shall be scheduled by the bureau when appropriate.

(s)

General (Level III) trauma facility criteria.

Figure: 25 TAC §157.125(s)

(t)

Basic (Level IV) trauma facility criteria.

Figure: 25 TAC §157.125(t)

§157.128. Denial, Suspension, and Revocation of Trauma Facility Designation.

(a)

A hospital's application for designation may be denied or a trauma facility's (facility) designation may be suspended or revoked for, but not limited to, the following reasons:

(1)

failure to comply with the statute and these sections;

(2)

willful preparation or filing of false reports or records;

(3)

fraud or deceit in obtaining or attempting to obtain designation status;

(4)

refusal to submit data to the state trauma registry;

(5)

failure to maintain required licenses, designations, and accreditations or when disciplinary action has been taken against the hospital by a licensing agency;

(6)

failure to have appropriate staff or equipment required for designation as described in §157.125 of this title (relating to Requirements for Trauma Facility Designation);

(7)

abuse or abandonment of a patient;

(8)

unauthorized disclosure of medical or other confidential information;

(9)

alteration or inappropriate destruction of medical records;

(10)

refusal to render care because of a patient's race, sex, creed, national origin, sexual preference, age, handicap, medical problem, or inability to pay; or

(11)

criminal conviction(s) as described in the Occupations Code, Chapter 53, Subchapter B.

(b)

Occasional failure of a hospital or facility to meet designation criteria shall not be grounds for denial, suspension or revocation by the Bureau of Emergency Management (bureau), if the circumstances under which the failure occurred:

(1)

do not reflect an overall deterioration in quality of and commitment to trauma care; and

(2)

are corrected within a reasonable timeframe by the hospital or facility.

(c)

If the bureau proposes to deny, suspend, or revoke a designation, the bureau shall notify the hospital or facility at the address shown in the current records of the department. The notice shall state the alleged facts that warrant the action and state that the hospital or facility has an opportunity to request a hearing in accordance with the Administrative Procedure Act, Government Code, Chapter 2001.

(1)

The hospital or facility shall request a hearing in writing and submit it to the bureau chief within 15 days after the date of the denial, suspension, or revocation notice.

(2)

If the hospital or facility does not request a hearing in writing, after being sent the notice of opportunity for hearing, it is deemed to have waived the opportunity for a hearing and the denial, suspension, or revocation decision shall stand.

(d)

Six months after the denial of a hospital's application for designation, the hospital may reapply for trauma facility designation as described in §157.125 of this title.

(e)

When a designation has been suspended, the suspension shall be in effect a minimum of 10 days. Upon completion of the assigned suspension time, designation shall resume.

(f)

One year after the revocation of a facility designation, the hospital may reapply for designation as described in §157.125 of this title. The bureau may deny designation if the bureau determines that the reason for the revocation continues to exist.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 10, 2000.

TRD-200002580

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: September 1, 2000

Proposal publication date: October 29, 1999

For further information, please call: (512) 458-7236