[30 Pa.B. 5363]
[Continued from previous Web Page] Comment
Subsection (a)(1)(ii) should be revised to insert the word ''service'' after the first time ''ambulance'' appears in that subparagraph, and the language ''providing guidance'' should be removed because it repeats the introductory language in paragraph (1).
Response
The absence of the term ''ambulance'' was an error and has been corrected. Although the introductory language in subparagraph (ii) does, to some extent, repeat the introductory language in paragraph (1), the Department has not removed it because the repetition makes sense within the structure of the paragraph, particularly when considering how subparagraphs (i), (iii) and (iv) are worded.
Other Changes
The term ''base station'' is removed from subsection (b)(2) and (5) and is replaced with ''medical command'' in paragraph (2).
Subchapter B. Prehospital and Other Personnel
Section 1003.21 (relating to ambulance attendant) is amended to explain the ambulance attendant's role as a staff member of an ambulance service and to identify the skills an ambulance attendant may perform when serving on an ambulance crew.
Comment
The American Red Cross does not offer an advanced first aid course. The reference to that course in this section should be changed.
Response
The American Red Cross does not offer a course that it labels ''Advanced First Aid.'' Nevertheless, the reference in this section to ''advanced first aid course'' is retained as a generic label. The definition of ''ambulance attendant'' in section 3 of the EMS provides that for an individual to be considered an ambulance attendant that person must have completed a course in advanced first aid sponsored by the American Red Cross or an equivalent program approved by the Department. Although the American Red Cross does not offer a course that it labels ''advanced first aid,'' it does offer courses that are an advanced first aid course or include comprehensive training in advanced first aid, and which are simply not titled ''advanced first aid,'' such as its Emergency Response Course.
Comment
There is no support in the EMS act for the proposal to permit an ambulance attendant to use an automated external defibrillator (AED) even if under the approval of the ambulance service medical director.
Response
The Department's proposed regulations were published at almost the same time the good Samaritan civil immunity for use of AED statute (42 Pa.C.S. § 8331.2) went into effect. Clearly, persons such as ambulance attendants have the authority to use an AED under that statute. However, when they are responding to an emergency as part of an ambulance crew, a patient is entitled to expect greater control and oversight over the ambulance attendant's use of an AED than the patient might expect if the same individual responded to the emergency as a good Samaritan. Subsection (c)(11) is revised, however, to clarify that a BLS ambulance service that employs AEDs needs to secure the services of a physician who directs its use of AEDs rather than a physician who is required to function as an overall medical director for the BLS ambulance service.
Comment
The Department should reconsider the proposed removal of the requirement that an ambulance attendant be at least 16 years of age. Furthermore, if a regulation addressing one type of prehospital practitioner includes a minimum age requirement, all regulations pertaining to certification requirements for preshospital personnel should include a minimum age requirement.
Response
The Department received similar comments for its other regulations that present criteria for qualifying as a type of prehospital practitioner. The comment will not be repeated in the discussion of the comments to those other regulations.
As explained in the Preamble to the proposed rulemaking, the Department proposed to delete the 16 years of age criterion that had been in this regulation because the EMS act sets no age requirement for an ambulance attendant. The age requirement for an ambulance attendant is regulated by the child labor laws in the Commonwealth, not the EMS act. The child labor laws prohibit a minor under 16 years of age from serving as an ambulance attendant. See sections 2 and 7.3(g) of the Child Labor Law (43 P. S. §§ 42 and 48.3). The Department decided not to repeat in its regulations the age requirement of the Child Labor Law because the Department does not administer that law and because that law may change. However, in consideration of the concern that has been expressed, the Department has amended subsection (a) to state that one of the criteria for serving as an ambulance attendant is satisfying the age requirement for an ambulance attendant under the Child Labor Law. The reason a specific minimum age requirement is included in some of the other regulations, such as § 1003.22(b)(1)(ii) (relating to first responder), is that the age for that type of preshospital practitioner is expressly established by the EMS act. See 35 P. S. § 6931(a.1)(2)(ii).
Comment
Courses in advanced first aid other than those offered by the American Red Cross should be accepted and mentioned in the regulation.
Response
Other courses may be accepted by the Department. The Department will not list them in this section because the list could change. The Department, in consultation with a technical advisory committee of PEHSC, publishes a notice in the Pennsylvania Bulletin listing those courses from time to time under the definition of ''ambulance attendant'' and the responsibility imposed upon the Department under the nonmedical good Samaritan civil immunity statute (42 Pa.C.S. § 8332).
Other Changes
Since the American Red Cross does not offer a specific course labeled ''advanced first aid,'' the Department has had to look at courses it does offer which teach advanced first aid skills. However, some of those courses may emphasize different advanced first aid skills and some may go beyond advanced first aid skills and offer training in skills that an ambulance attendant should not be performing. Consequently, the Department proposed in subsection (c)(13) to publish in the Pennsylvania Bulletin, at least annually, a list of skills taught in the American Red Cross courses which are truly advanced first aid skills, and then to permit an ambulance attendant to perform only the skills among those listed for which the ambulance attendant actually received training. The Department has sought to clarify this paragraph by dividing it into subparagraphs, and by adding the statement that an ambulance attendant may not perform a skill taught in a course approved by the Department under that paragraph (which may include skills in addition to advanced first aid skills) unless the skill is contained in the list of advanced first aid skills the Department publishes in the Pennsylvania Bulletin.
The Department has revised proposed subsection (c)(3) to remove the language ''resuscitation mask, nasal cannula, nonrebreather mask and bag valve mask'' to specify how an ambulance attendant may administer oxygen. As revised, this provision authorizes an ambulance attendant to administer oxygen only in a manner consistent with the ambulance attendant's training.
The Department has substituted ''skills'' for ''services'' in various places in this section. The reason for this revision is discussed in response to the next comment.
Section 1003.22 (relating to first responder) specifies the qualifications and functions of a first responder.
Comment
Instead of using the term ''BLS services'' the regulation should use the term ''BLS objectives.''
Response
The term ''service'' has the potential to cause confusion because it is sometimes used to refer to an ambulance organization (for example, BLS ambulance service) and other times used to refer to the procedures performed by prehospital personnel (for example, BLS services). Here it is used to refer to the latter. However, the EMS act also uses this term in both contexts. In fact, two of the terms defined in section 3 of the EMS act are ''ambulance service'' and ''basic life support services.'' While the context of the sentence should clearly convey how the term is being used, the Department has revised this regulation to substitute the term ''skills'' for ''services'' in several places.
Comment
The intent of subsection (e)(4) is not clear. It appears to state that some courses are offered which may not be counted as continuing education credits or may not be used to expand the scope of the first responder's duties. The Department should amend subsection (e)(4) to clarify its intent.
Response
The Department agrees with the comment. Proposed subsection (e)(4) was not designed to address what courses are or are not acceptable for continuing education credit. The Department has revised subsection (e)(4) to clarify its intent.
The Department certifies first responders. One criterion for certification is that the individual must have completed a first responder training course approved by the Department. However, just as it recognizes for ambulance attendants, courses that provide training in addition to that which is appropriate for an ambulance attendant, the Department will also recognize, for first responder certification purposes, courses that meet or exceed the standards of a first responder training course that the Department has approved. A person who completes such a course will be able to qualify for first responder certification, but may perform skills for which that person has received training only if those skills are also taught in a Department-approved course. The Department will publish a list of these skills at least annually.
At present, the benchmark for courses approved by the Department for first responder training is the Emergency Response Course taught by the American Red Cross--which is also the American Red Cross's course in advanced first aid--the course establishing the scope of practice for an ambulance attendant. The Department is also developing its own first responder course and has recognized a few other courses for first responder training.
A first responder's scope of practice may, in the future, exceed that of an ambulance attendant. This would occur if the Department develops or approves courses for first responder training which teach skills in addition to those taught in an advanced first aid course sponsored by the American Red Cross.
If that occurs, additional skills will be added to the list of first responder skills published by the Department. However, a first responder may have taken a training course before those additional skills were added to the approved training. The regulation requires the first responder to receive training in the listed skills before performing them, but permits the first responder to receive that training through continuing education rather than by completing a revised first responder training course.
The Department has revised proposed subsection (e)(2) to more clearly convey these standards. It has divided the proposed paragraph into subparagraphs and has added the statement that a first responder, regardless of which course he has taken, may not perform a skill unless the skill is contained in the list of first responder skills published by the Department in the Pennsylvania Bulletin.
Comment
First responders have liability protection under the EMS act. The proposed sentence that states the section does not prohibit a first responder from providing EMS as a good Samaritan should be removed. This sentence may encourage a prehospital practitioner to attempt to bypass systematic responses orchestrated through the EMS system.
Response
No change is made. The same comment is made to several of the sections pertaining to prehospital personnel. It will be addressed here in a generic manner and will not be repeated in the discussion of the other sections.
While first responders and other prehospital personnel are afforded limited civil liability protection under sections 11(j)(2) and 13 of the EMS act (35 P. S. §§ 6931(j)(2) and 6933), that protection may only apply when the prehospital practitioner is responding to an emergency within the scope of the EMS act, that is, as part of the crew of an ambulance or on behalf of a QRS. There may be occasions, however, when a first responder or other prehospital practitioner is off duty and comes upon an emergency as an individual. It is not clear whether the civil liability protection afforded by the EMS act would apply in that case. However, if it would not, the individual would be afforded the limited civil liability protection given by the good Samaritan statute provided the prehospital practitioner satisfies the statutory requirements to qualify for good Samaritan status. The questioned sentence is included in the section to encourage prehospital practitioners to act as good Samaritans if there is a need to do so. It does not authorize, nor is it intended to encourage, first responders and other prehospital personnel to circumvent systematic responses to emergencies by dispatched ambulance services and QRSs.
Section 1003.23 (relating to EMT) specifies the qualifications and role of an EMT.
Comment
Although proposed subsection (e)(2) would allow an EMT to transport a patient with an intravenous catheter, it would not permit the EMT to transport the patient with medication running. Prohibiting transportation of a patient with medication running is overly restrictive. An exception should be made to allow the transport of a patient with an intravenous catheter with medication running if continued running of the medication is part of the patient's normal outpatient protocol.
Response
The Department agrees. It has revised subsection (e)(2) to permit the transport of a patient with an intravenous catheter with medication running if the medication is part of the patient's normal treatment plan, and the care is consistent with the Statewide BLS medical treatment protocols.
Comment
The intent of proposed subsection (e)(3) is not clear. It appears to state that some courses are offered which may not be counted as continuing education credits or may not be used to expand the scope of the EMT's duties. The Department should amend subsection (e)(3) to clarify its intent.
Response
The Department agrees. The same comment was made to proposed § 1003.22(e)(4). The Department has revised proposed subsection (e)(3) and added a subsection (f) to include provisions similar to those made to § 1003.22(e)(4) for reasons similar to those discussed in responding to the comment to proposed § 1003.22(e)(4).
Section 1003.23a (relating to EMS instructor certification) is new. Current provisions for EMT instructor certification have been removed from § 1003.22 and, with some revision, have been inserted in this section. There is no statutory provision directing the Department to issue EMS instructor certifications. However, the Department offers this certification program to potential instructors to improve the quality of training in EMS training institutes. There was some discussion of this section in the comments, but no recommendation for change was received.
Changes
Subsection (a)(6) is revised to include current certification as a CPR instructor as an alternative qualifying criterion to current certification in CPR.
Subsection (b)(3) is revised to permit the applicant for renewal of an EMS instructor certification to document conducting 60 hours of teaching during the previous 3 years rather than 20 hours of teaching in each of those years. The paragraph has also been revised to clarify that the teaching may be in EMS or rescue courses.
Subsection (b)(4) is revised to remove the term ''current'' in referring to certification as an EMT-paramedic. Unlike some of the certifications issued by the Department, certification as an EMT-paramedic is permanent.
Subsection (b)(6) is revised to postpone the requirement of taking an EMS instructor update program, as a condition for renewal of EMS instructor certification, until October 7, 2003. It will take some time for the Department and regional EMS councils to develop and administer these programs.
Section 1003.24 (relating to EMT-paramedic) specifies the qualifications and role of an EMT-paramedic.
Comment
The Preamble to the proposed rulemaking states that subsection (c) (relating to transition of EMT-paramedic I and EMT-paramedic II certification to EMT-paramedic certification) would be deleted, but there is no beginning bracket in the annex to that preamble before subsection (c) to show that the subsection would be removed. This needs to be corrected in final rulemaking.
Response
The Department agrees. A bracket was included before the prior text of subsection (c) in the proposed rulemaking the Department filed with the LRB to indicate that the Department was proposing to repeal that language and substitute new text in its place. An error occurred in reprinting the proposed revisions to the section. The Department has corrected the error.
Comment
The intent of proposed subsection (d)(19) is not clear. It appears to state that some courses are offered which may not be counted as continuing education credits or may not be used to expand the scope of the EMT-paramedic's duties. The Department should amend subsection (d)(19) to clarify its intent.
Response
The Department agrees. The same comment was made to proposed §§ 1003.22(e)(4) and 1003.23(e)(3). The Department has revised proposed subsection (d)(19) and added a subsection (e) to include provisions similar to those made to § 1003.22(e)(4) for reasons similar to those discussed in responding to the comment to proposed § 1003.22(e)(4).
Comment
Because an EMT-paramedic requires medical command authorization from an ALS service medical director as a precondition to performing ALS skills, this regulation should state that an EMT-paramedic may not perform ALS skills when staffing a BLS ambulance.
Response
The same comment was made with respect to prehospital registered nurses. It will not be repeated in the discussion of § 1003.25b (relating to prehospital registered nurses).
The recommended revision is not made. Subsection (d) does state that the ALS skills set forth in the subsection may be performed by an EMT-paramedic only if the EMT-paramedic has medical command authorization. Medical command authorization is not issued to prehospital personnel who work for BLS ambulance services. Section 1003.28(a) (relating to medical command authorization) states that the ALS service medical director's grant of medical command authorization to an EMT-paramedic or prehospital registered nurse applies only to the ALS ambulance service for which that physician makes the decision. Moreover, the contention that an EMT-paramedic or prehospital registered nurse may not perform ALS skills on a BLS ambulance is not entirely correct. Either prehospital practitioner may perform ALS skills on a BLS ambulance when that practitioner responds to an emergency on behalf of an ALS ambulance service for which the practitioner has medical command authorization, and then enters the BLS ambulance to attend to the patient during transport of the patient to a receiving facility by the BLS ambulance.
Comment
The Department should maintain a list of advanced skills that are not taught in EMT-paramedic training courses, which an EMT-paramedic could perform with additional training, continuing education and medical director approval. Similar provisions should also be made for EMTs and first responders.
Response
The Department rejects the recommendation. An ALS service medical director may apply for an exception to the scope of practice limitations imposed upon an EMT-paramedic, under § 1001.4 (relating to exceptions), if an ALS service medical director wants an EMT-paramedic to be able to perform, for a specific ALS ambulance service, skills in addition to those taught in an EMT-paramedic training course and believes that the EMT-paramedic is qualified to do so. EMTs and first responders may also apply for an exception to their scope of practice limitations.
Comment
As an addendum to the preceding comment, the regulation should not include performing central venous cannulation, urinary catheterization and the use of gastric tubes. These are types of procedures that should be limited to EMT-paramedics with additional training.
Response
The recommendation is rejected. These are skills that have been taught in EMT-paramedic NSC for many years. Also, an ALS service medical director is required to determine the competency of the EMT-paramedic to perform these skills before granting and renewing medical command authorization to the EMT-paramedic.
Section 1003.25a (relating to health professional physician) is revised to eliminate conditions the section previously specified for a physician to function as a health professional physician. The EMS act's definition of ''health professional'' states that a physician qualifies to function in that capacity if the physician has ''education and continuing education in [ALS] and prehospital care.'' See 35 P. S. § 6923. It does not provide for the Department to certify health professional physicians or to set standards physicians would be required to meet to serve as health professional physicians. No comment addressing this section was received. This section is adopted as proposed.
Section 1003.25b specifies the qualifications and role of a prehospital registered nurse.
Comment
Subsection (c) proposes that the scope of practice of a prehospital registered nurse include the scope of practice of an EMT-paramedic and other ALS services authorized by the Professional Nursing Law. The Professional Nursing Law does not mention ALS services. Either delete the acronym ''ALS'' from subsection (c), or explain how it applies.
Response
The Department agrees that the term ''ALS'' is not required and has deleted it from subsection (c).
Comment
The scope of practice of prehospital registered nurses and EMT-paramedics should be the same. Delete any reference to expanding that scope of practice in accordance with the Professional Nursing Law (63 P. S. §§ 211--225.5).
Response
This recommendation is rejected. Section 11(e.1)((7) of the EMS act provides that consistent with the provisions of the EMS act a prehospital registered nurse's scope of practice is governed by the Professional Nursing Law and 49 Pa. Code Chapter 21 (relating to State Board of Nursing). A prehospital registered nurse should be authorized to perform those nursing skills which exceed the scope of practice of an EMT-paramedic, but which facilitate the provision of EMS to a patient, when authorized by a medical command physician through either direct medical command orders or standing treatment protocols.
Other Changes
In subsection (c)(3) the Department has inserted the term ''medical'' before ''treatment protocols.''
Section 1003.26 (relating to rescue personnel) pertains to the Department's certification of rescue personnel. It is amended to clarify that the Department approves courses for rescue personnel and issues certifications to persons who complete those courses. Receipt of such a certification is not, however, required by law as a precondition to freeing an entrapped person. The Department is granted no regulatory oversight over rescue activities under the EMS act. The Department approves rescue programs and issues rescue technician certificates as a public service, in an effort to ensure that there are a sufficient number of personnel throughout this Commonwealth who have appropriate training and skills to perform rescues. The certification merely reflects the Department's opinion that the person is qualified to perform the rescues taught in the approved course. The section clarifies that receiving a rescue technician certification issued by the Department is not a legal precondition to performing rescues.
No comments addressing this section were received. This section is adopted as proposed.
Section 1003.27 (relating to disciplinary and corrective action) identifies the grounds for discipline against prehospital personnel, the rules applicable to disciplinary proceedings, and the sanctions the Department may impose when discipline is warranted. No comments to this section were received. The section is adopted as proposed except ''personnel'' is replaced by ''practitioner'' in subsection (a)(15).
Section 1003.28 (relating to medical command authorization) specifies the criteria for an ALS service medical director to grant medical command authorization, and the procedures for EMT-paramedics and prehospital registered nurses to appeal ALS service medical director decisions to deny, restrict or remove medical command authorization.
Comment
The first two sentences of subsection (b)(3) and the last sentence of subsection (c)(2) are unclear. They would be clearer if they were broken into shorter sentences, or when appropriate, a list of requirements.
Response
The Department has attempted to make this section clearer by dividing the specified sentences in subsection (b)(3) into shorter sentences, and by revising the referenced sentence in subsection (c)(2) so that it lists requirements.
Comment
If the decision of the ALS service medical director is overturned by the regional EMS medical director or the Department, it is unclear as to who takes legal responsibility for the future actions of the EMT-paramedic. The ALS service medical director, who believed the preshospital practitioner to be deficient in the ability to care for patients, should not be responsible. The Department should clarify who will serve as the ALS service medical director of the prehospital practitioner whose medical command authorization is reinstated.
Response
It is beyond the scope of the Department's statutory authority to do what is being requested. The EMS act provides that the decision of the ALS service medical director to remove an individual's medical command authorization may be overturned by the regional EMS medical director or the Department. Conceivably, the ALS service medical director's decision could even be overturned by the Commonwealth or the Supreme Court of Pennsylvania. If the ALS service medical director's decision is overturned, the ALS service medical director will need to either accept the decision, appeal it and attempt to secure a stay, or no longer function as the medical director for the ALS ambulance service with which the practitioner is employed. The matter of civil responsibility for actions of the prehospital practitioner is not a matter regulated by the Department and cannot be addressed in the Department's regulations. These concerns should be addressed to the Legislature rather than to the Department.
Comment
In subsection (e) the proposal to remove the authority to appeal the restriction of medical command authorization should be rejected.
Response
The Department rejects the recommendation. Section 11(d) and (e.1) of the EMS act addresses appeals of decisions to remove medical command authorization. Proposed subsection (c)(3) clarifies that the type of restriction that an ALS service medical director may place on medical command authorization, short of removal of that authorization, may not preclude the prehospital practitioner from performing any of the skills included within the scope of the individual's certification or recognition which are also permitted by the medical treatment protocols for the region. In essence, the restrictions may only impose additional safeguards, such as additional supervision. This is not action for which the EMS act grants any appeal rights.
Comment
This section should be revised to permit a regional EMS medical director to appoint a hearing officer.
Response
The recommendation is rejected. The EMS act places the decisionmaking responsibility on the regional EMS medical director. The regional EMS medical director cannot delegate that responsibility to another person. The regional EMS medical director may, however, assign another person to conduct the hearing as long as the regional EMS medical director reviews the entire record and personally decides the matter. Section 1003.29 (relating to continuing education requirements) specifies the continuing education requirements and options for prehospital personnel.
Comment
In subsections (a)(1) and (b)(1) the Department should clarify whether the proposed medical and trauma continuing education requirements are applicable to only the first full certification following October 14, 2000, or whether they also apply to all subsequent recertifications.
Response
The proposed trauma and medical continuing education requirements are adopted as proposed. They will apply not only to the first full certification period, but to all subsequent recertifications. The language has been revised to clarify that intent.
Other Changes
In subsections (c) and (d) the Department had proposed that the medical and trauma continuing education requirements for EMT-paramedics and prehospital registered nurses commence in 1999. The Department has revised these subsections to provide that these requirements will commence in 2002. This amount of deferral time from the date of adoption of these new requirements is more realistic from an administrative perspective for the Department, regional EMS councils and continuing education sponsors.
Section 1003.30 (relating to accreditation of sponsors of continuing education) specifies the criteria that needs to be satisfied for an organization to serve as a continuing education sponsor.
Comment
Contrary to the proposal in subsection (d), the Department should not permit continuing education sponsors to assign credit to the courses they offer.
Response
The Department does not currently permit continuing education sponsors to assign credit to the courses that they offer. However, the Department wants to retain that option. As proposed, a continuing education sponsor could assign credit for a course only under express authorization from the Department. The continuing education sponsor would be required to comply with the regulatory criteria in doing so. This section is adopted as proposed.
Section 1003.31 (relating to credit for continuing education) is new. It defines what constitutes a credit hour and time units of instruction for which credit will be awarded. It also provides for continuing education credit to be awarded for teaching, self study courses and other courses not presented in a classroom setting, and for courses offered by organizations with National or State accreditation to provide education. Additional matters addressed are how continuing education credits are to be reported to prehospital personnel, and the procedure for resolving disputes when a prehospital practitioner believes that he has not received credit that has been earned.
Comment
This section uses the term ''prehospital practitioner'' but that term is not defined in the regulations.
Response
This comment was addressed in the discussion of comments to § 1001.2. The term is used throughout the regulations and is now defined in § 1001.2.
Comment
Clarify what is meant by the statement in proposed subsection (a) that credit may not be received for other than 30 or 60-minute units of instruction, however the course shall be at least 60 minutes in length.
Response
The Department believes that the statement is clear. It has not revised the language. One credit hour is awarded for each 60 minutes of instruction. A continuing education course must be at least 60 minutes in length. If the course extends beyond 60 minutes, no credit will be given for education in other than 30 or 60-minute increments. For example, a course that provides instruction for 90 minutes will be assigned 1 1/2 credits; a course that provides instruction for 100 minutes will also be assigned 1 1/2 credits.
Changes
In subsection (c) the proposed language ''a training institute for prehospital personnel accredited by the Department'' is replaced with ''an EMS training institute.'' The term ''EMS training institute'' is defined in § 1001.2 to mean the same as the language it replaces.
Section 1003.32 (relating to responsibilities of continuing education sponsors) is new. This section specifies responsibilities of a continuing education sponsor with respect to keeping records of attendance, reporting attendance, having a mechanism for course evaluation, retaining records, monitoring compliance, and making available various reports and records to the Department.
Section 1003.33 (relating to advertising) is also a new section. It addresses how a continuing education sponsor may advertise a course approved by the Department, as well as a course for which Department approval is being sought, but has not yet been obtained.
Section 1003.34 (relating to withdrawal of accreditation or course approval) is another new section. It provides for the Department to withdraw accreditation, downgrade accreditation to provisional status, or withdraw approval of a continuing education course applicable to any future presentation of the course.
No comments addressing these sections were received. Sections 1003.32--1003.34 are adopted as proposed, except the text of § 1003.32(a) is replaced with language addressing the procedure for securing approval of a new continuing education course. As a result of this addition, the text of proposed § 1003.32(a)--(h) is moved to subsections (b)--(i).
The Department proposed to delete Subchapter C (relating to air ambulance personnel), and address much of the subject matter of this subchapter in Chapter 1007 (relating to the licensing of air ambulance services-rotorcraft). No comments addressing the proposed repeal of this subchapter were received. Subchapter C is rescinded.
Chapter 1005. Licensing of BLS and ALS Ground Ambulance Services
This chapter specifies the licensure and operating criteria for ground ambulance services.
Section 1005.1 (relating to general provisions) is amended to state that Chapter 1005 applies to ground ambulance services. A later chapter, Chapter 1007, pertains to air ambulance services.
Comment
The first word ''No'' in the second sentence of subsection (a) is bracketed in the Pennsylvania Bulletin to show the proposed deletion of that word. A replacement word such as ''A'' needs to be inserted as the first word of the sentence. Also, the word ''exempted'' is deleted in the Pennsylvania Bulletin version of the regulation. Without it, the sentence makes no sense. That term needs to be inserted. Similar revisions also need to be made to § 1007.1(a) (relating to general provisions for licensing of air ambulance services).
Response
The Department agrees that revisions are required to subsection (a) as recommended. The proposed language the Department submitted to the LRB for subsection (a) was different than the actual language published. Errors occurred in printing the revised language. The Department has corrected the errors. The language in proposed § 1007.1(a) is somewhat different than that contained in subsection (a). That language is appropriate and does not require revision.
Comment
Subsection (c)(1) labels an ALS ambulance that transports patients as a mobile intensive care unit vehicle. The labeling of an ambulance that does not have the capability to perform a 12 lead electrocardiogram, do any invasive monitoring whatsoever, and is not required to carry pulse oximetry equipment, as a ''mobile intensive care unit,'' is incorrect and misleading to the public.
Response
The Department agrees. The term ''mobile intensive care unit'' has been employed for many years, but that does not make the use correct. The Department believes that the term exaggerates the function of a transporting ALS ambulance. The Department has revised the term by substituting ''ALS'' for ''intensive.''
Section 1005.2 (relating to applications) identifies information solicited by an application for an ambulance service license and the process for an entity to apply for an ambulance service license and an amendment of a license.
Comment
Does this section permit an entity to apply for an ambulance service license to operate in an area that is already serviced by an ambulance service?
Response
An entity may apply for an ambulance service license to operate in an area that is already serviced by an ambulance service. This section does not address that issue. However, no provision of the EMS act or Part VII of the Department's regulations prohibits the application.
Comment
Contrary to the proposal, the Department should not revise subsection (a)(5) to delete solicitation of information on mutual aid agreements.
Response
This recommendation is rejected. The provision is being removed because the existence of mutual aid agreements is not material to whether the applicant should be licensed. However, the removal of the provision soliciting information on mutual aid agreements has no bearing upon whether an ambulance service may continue to have mutual aid agreements with other ambulance services. It bears noting, nevertheless, that an ambulance service may not use a mutual aid agreement as a mechanism to shift its licensure responsibilities to another ambulance service. For example, an ALS ambulance service may not satisfy the requirement that it operate 24 hours-a-day, 7 days-a-week, by discontinuing its operations for periods of time and arranging for another ALS ambulance service to respond to its calls during those periods.
Comment
A regional EMS council should not be required to conduct an onsite survey of an applicant for ambulance service licensure until it determines that the application is complete.
Response
The Department agrees. It did not provide otherwise in the proposed rulemaking. Nevertheless, upon additional consideration of this section, the Department concludes that further elaboration of the licensure mechanics is required. The Department has revised subsection (b)(2) to provide that the regional EMS council is to return an incomplete application to the applicant. It has also revised that paragraph to state that a regional EMS council will return to an applicant an inaccurate application, before conducting an onsite survey, when it determines the inaccuracy of any information provided in the application that is verifiable without the regional EMS council conducting an onsite survey. A regional EMS council should not be wasting its resources in conducting an onsite survey when an application needs to be returned to the applicant for the purpose of correcting errors. The Department has revised subsection (c) to state that a regional EMS council is to conduct an onsite survey only after it has received a complete application and has verified the accuracy of the information included in the application which it is able to verify without conducting an onsite inspection.
Comment
In subsection (a)(5) instead of providing that the license application will include information pertaining to an emergency service area an ambulance service commits to serve. It should provide that the license application shall identify the emergency service area the ambulance service would be available to serve.
Response
The Department agrees that solicitation of information as to where an ambulance service is available or plans to serve is more appropriate, especially if ambulance service dispatch legislation is passed. The Department has revised subsection (a)(5) and subsection (d) accordingly.
Comment
Subsection (a)(9) should not require the applicant to divulge whether it intends to place its ambulances under systems status management practices rather than at specific building locations.
Response
The Department disagrees with the comment. Subsection (a)(9) is adopted as proposed. Systems status management is a process whereby an ambulance service locates its ambulances in different locations on different days and at different times so that it will be closer to anticipated calls for emergency assistance based upon historical patterns of requests for ambulance assistance. For example, during the normal business workweek it may place an ambulance near an area where business is concentrated. It may place the same ambulance at other locations when those businesses are not in full operation.
Some of the criteria for licensure are that the ambulance service will operate in a safe and efficient manner and that its ambulances will be adequately staffed. See 35 P. S. § 6932(h)(2), (3) and (4). To make those determinations, the Department needs information regarding how the ambulance service intends to operate.
Comment
In proposed subsection (e), which requires an ambulance service to apply for and secure an amendment of its license before substantively altering the location or operation of its ambulances within a region, the words ''physical building'' should be inserted before ''location.''
Response
The Department rejects the recommendation. As discussed in the response to the previous comment, an ambulance service may elect to employ systems status management as its means for placing ambulances. Since the location of its ambulances would not be constant, the location of its physical building location would not be very significant. This is particularly true with respect to the duty to meet statutory staffing requirements. The Department is required to determine that an applicant will satisfy statutory staffing standards. The Department makes that determination after considering information such as where the ambulance service conducts operations and where its personnel are located. When an ambulance service intends to conduct operations a great distance from where it had previously operated, the service may not be able to do so for all required times with the same complement of prehospital personnel. The Department needs to determine that the ambulance service is capable of operating appropriately under those circumstances before the ambulance service commences those operations.
Other Changes
In subsection (a)(2) the Department has replaced the word ''licensure'' with ''license.''
The Department has added under subsection (a)(10), which relates that the license application will solicit the names, titles and summary of responsibilities of persons who will be staffing the ambulance service as officers, directors or other officials, and information as to any misdemeanor or felony convictions, or disciplinary sanctions, that have been imposed against them. Section 12(h)(1) of the EMS act (35 P. S. § 6932(h)(1)) provides that one criterion for licensure is that the ambulance service will be staffed by responsible persons. The Department needs information such as that specified in subsection (a)(10) to be able to make the assessment of whether the applicant for an ambulance service license will be staffed by responsible persons.
The Department has revised subsection (b) to provide procedures for an applicant to secure a single license to locate ambulances and conduct operations in multiple EMS regions. This is a departure from the previous regulations. They required a separate license for ambulance service operations in each region where an ambulance service stations its ambulances. The change in regulatory requirements to require an entity to secure a single license covering all of its ambulance service operations in this Commonwealth will be discussed in greater detail under § 1005.5 (relating to licensure).
The Department has also removed the text of proposed subsection (d), which pertained to placing a new ambulance in operation, moved the text of proposed subsection (e) to subsection (d) and inserted new text in subsection (e) to describe application procedures for an ambulance service to amend its license to enable it to expand its operations into another EMS region.
Section 1005.2a (relating to change in ambulance fleet) is new. It deals with the subject matter that the Department had proposed to address in § 1005.2(d). Subsection (a) requires an ambulance service to submit a modification of ambulance fleet form to the appropriate regional EMS council before placing an additional or permanent replacement ambulance in operation. It also provides that an ambulance service may not operate the ambulance unless it is authorized to do so by the Department following inspection of the ambulance. These requirements are consistent with the legislative intent that before an ambulance is placed into service it is to be determined by the Department to be ''adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.'' See 35 P. S. § 6932(h)(2). If there is an extraordinary event that requires an ambulance service to secure a permanent replacement ambulance immediately, the ambulance service may seek an exception to the prior inspection requirement under § 1001.4.
Sometimes an ambulance breaks down and an ambulance service needs to replace it on a temporary basis immediately to continue serving the public. The acquisition of a new or replacement ambulance is an expected event and affords the ambulance service ample time to provide a regional EMS council with advance notice and an opportunity to conduct an inspection before the ambulance needs to be used. On the other hand, the need to secure a temporary replacement ambulance may arise unexpectedly. Consequently, the Department has adopted subsection (b) to permit an ambulance service to operate a temporary replacement ambulance without securing prior approval from the Department. The ambulance service will be required to file a temporary change of vehicle form with the appropriate regional EMS council no later than 24 hours after placing the temporary replacement ambulance in operation. The form may be filed by facsimile, electronic or regular mail. Upon receiving the form the regional EMS council will issue a letter authorizing use of the temporary replacement for 7 days, but may later extend that time period. The regional EMS council will conduct an inspection of the temporary ambulance if it will be used for more than a few days.
Section 1005.3 (relating to right to enter, inspect and obtain records) pertains to an ambulance service's duty to permit employes of the Department or regional EMS councils to conduct inspections, review the applicant's or ambulance service's policies, and secure copies of records from it. It clarifies that the ambulance service has a duty to permit the review and that its failure to do so constitutes misconduct and a basis for discipline. No comments to this section were received. The Department has corrected a typographical error. Otherwise, this section is adopted as proposed.
Section 1005.4 (relating to notification of deficiencies to applicants) pertains to how the Department and a regional EMS council interact with an applicant if there are deficiencies following an onsite inspection.
Changes
No comments addressing this section were received. Nevertheless, the Department has revised proposed subsection (a) to clarify that it applies when a regional EMS council completes an onsite inspection under either an application for a license or an application for an amendment of a license. Proposed subsection (e) is revised to clarify that the Department will act upon a license application within 30 days after the inspection process has been completed, unless the Department requires additional time to complete an investigation of those qualifications of an applicant which cannot be determined through the inspection process. The Department's experience is that additional time is most frequently required to determine whether persons staffing the ambulance service are responsible persons. This is particularly true if the Department becomes aware of criminal or disciplinary information not previously provided by the applicant to the regional EMS council.
Section 1005.5 (relating to licensure) identifies the indicia of licensure issued to an ambulance service and directs ambulance services where to place those items. This section also specifies some of the information included in the license certificate, and provides for the consolidation into one license a person's multiple licenses to operate ambulance services in this Commonwealth.
Comment
A certificate of need should be required as part of the licensure process because an over abundance of ambulance services results in a dilution of the skill base of prehospital personnel.
Response
The recommendation is rejected. Section 12(h)(1)--(5) of the EMS act establish five criteria that need to be met for an applicant to secure an ambulance service license. Demonstrating a ''need'' for the applicant to become an ambulance service and operate in a particular area is not one of the criteria. The Department is not permitted to add additional licensure criteria by regulation.
Changes
In subsection (b) the Department has added a sentence to explain that it will issue a new license certificate if there is a need to change information on an existing license certificate. For example, this would occur if an ambulance service that had been licensed to provide BLS services only becomes licensed to also provide ALS services.
Subsection (g) is added to provide that the Department will consolidate into a single license a person's multiple licenses to operate an ambulance service in this Commonwealth. The Ambulance Association of Pennsylvania has endorsed this shift in policy. While the Department believes that all entities that have more than one ambulance service license will welcome this change, it has drafted subsection (g) to afford an affected organization 60 days after October 14, 2000, to object to the consolidation and advance reasons in support of the objection. The license consolidations will not occur for 90 days after October 14, 2000. The Department will rule upon any objection that is filed with it in a timely manner before consolidating the licenses of the objecting person. Under § 1005.2, after October 14, 2000, any person that seeks to station and operate ambulances in more than one EMS region will need to submit a single application for licensure if not already licensed. If the person is already licensed but not conducting operations in multiple regions, it will need to apply for an amendment of its license.
Section 1005.6 (relating to out-of-State providers) recognizes the statutory permission for ambulance services not licensed in this Commonwealth to transport patients from outside the borders of this Commonwealth to facilities situated inside this Commonwealth's borders.
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