Application and Licensure Requirements Standards for the Licensure and Relicensure of Ground Ambulance Services

PURPOSE: This rule provides the requirement and standards related to the licensure and relicensure of ground ambulance services. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Application Requirements for Ground Ambulance Service Licensure. (A) Each applicant for ownership of an ambulance service license or relicense shall submit an application for licensure to the Bureau of Emergency Medical Services (EMS) no less than thirty (30) days or no more than one hundred and twenty (120) days prior to their desired date of licensure or relicensure. (B) An application shall include the following information: trade name of the ambulance service; location of vehicles; number of vehicles to be operated by the ambulance service; name, address, telephone numbers and e-mail address (if applicable) of operator of the ambulance service; name of manager; name, address, whether a medical doctor or doctor of osteopathy, telephone numbers, e-mail address (if applicable), and signature of medical director and date signed; certification by the medical director that they are aware of the qualification requirements and the responsibilities of an ambulance service medical director and agree to serve as medical director; name, address, telephone numbers and e-mail address (if applicable) of proposed licensee of the ambulance service; name of licensee’s chief executive officer; all ambulance service licensure and related administrative licensure actions taken against the ambulance service or owner by any state agency in any state; and certification by the applicant that the application contains no misrepresentations or falsifications and that the information given by them is true and complete to the best of their knowledge, and that the ambulance service has both the intention and the ability to comply with the regulations promulgated under the Comprehensive Emergency Medical Service Systems Act, Chapter 190, RSMo Supp. 1998. (C) Each ambulance service that meets the requirements and standards of the statute and regulations shall be licensed and relicensed for a period of five (5) years. (D) Ambulance services which are currently accredited by the Commission on Accreditation of Ambulance Services (CAAS) or the Commission on Accreditation of Medical Transportation Services (CAMTS) and have the required liability insurance coverage shall be considered to be compliant with the rules for ambulance services. Accredited ambulance services shall attach to their application evidence of accreditation and proof of their liability insurance coverage. The Bureau of EMS may conduct periodic site reviews as necessary to verify compliance. (2) Each vehicle operated as an ambulance shall meet the following vehicle design, specification, operation, and maintenance standards: (A) Vehicle Design and Specification Standards. In providing the transportation of patients, ambulance services shall utilize only vehicles specifically designed, manufactured, and equipped for use as an ambulance and which meet current (at date of vehicle manufacture) standards/specifications set forth by the U.S. Department of Transportation KKK-A-1822, the Commission on Accreditation of Ambulance Services Ground Vehicle Standard for Ambulances v.1.0 edition or the National Fire Protection Association 1917 Standard for Automotive Ambulances 2016 Edition. The Commission on Accreditation of Ambulance Services Ground Vehicle Standard for Ambulances v.1.0 edition is incorporated by reference in this rule as published in 2016 and is available at the Ground Vehicle Standard, 1926 Waukegan Road Suite 300, Glenview Il 60025-1770. This rule does not incorporate any subsequent amendments or additions. The National Fire Protection Association 1917 Standard for Automotive Ambulances 2016 Edition is incorporated by reference in this rule as published in 2016 and is available at the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169-7471. This rule does not incorporate any subsequent amendments or additions. Exceptions to these standards/ specifications may include the following. SENIOR SERVICES 1. Image elements (such as paint) may be altered to the agency’s preference; 2. Variation of warning lights is allowed for: type and color of lens, strobe lights in lieu of halogen lights, additional warning lights beyond the U.S. Department of Transportation KKK-A-1822, National Fire Protection Association 1917 Standard for Automotive Ambulances 2016 edition or the Commission on Accreditation of Ambulance Services Ground Vehicle Standard for Ambulances v.1.0 edition specifications; 3. Power supply and equipment in the patient compartment may be altered to the agency’s preference; and 4. Other variations may be allowed by the Bureau of EMS; (B) Operational Standards. 1. Ambulance services shall provide the quantity of ambulance vehicles, medical supplies and personnel to meet the emergency call volume which can be reasonably anticipated for their ambulance service area. 2. Ambulance services which are the 911 provider or the recognized emergency provider shall ensure prompt response to all requests to that service for emergency care originating from their ambulance service area twenty-four (24) hours per day, each and every day of the year, and shall provide patients with medically necessary care and transportation in accordance with that ambulance service’s protocols. 3. Public liability insurance or proof of self-insurance, conditioned to pay losses and damage caused by or resulting from the negligent operation, maintenance, or use of ambulance services under the service’s operating authority or for loss or damage to property of others. Documents submitted as proof of insurance shall specify the limits of coverage and include the ambulance service license number. Public liability coverage for ambulance services which transport patients in the patient compartment of a vehicle shall meet or exceed— A. Two hundred fifty thousand dollars ($250,000) for bodily injury to, or death of, one (1) person; B. Five hundred thousand dollars ($500,000) for bodily injury to, or death of, all persons injured or killed in any one (1) accident, subject to a minimum of two hundred fifty thousand dollars ($250,000) per person; and C. One hundred thousand dollars ($100,000) for loss or damage to property of others in one (1) accident, excluding cargo; and (C) Maintenance Standards. The ambulance service shall have a policy to provide for the effective maintenance of all its ambulances and maintain records that demonstrate compliance with such policy. (3) Each vehicle operated as an ambulance shall meet the following equipment requirements: (A) Documentation that each vehicle is equipped with pediatric and adult medical supplies and equipment as required by the ambulance service medical director for the various patient care activities in the out-of-hospital setting to which it will respond. Each service shall be able to produce these records for inspection during normal business hours; and (B) The ambulance service shall have a policy and provide for the effective maintenance, storage, usage and replacement of its medical equipment, devices and medications. (4) Each vehicle operated as an ambulance shall meet the following staffing requirements: (A) When transporting a patient, at least one (1) licensed EMT, registered nurse, or physician shall be in attendance with the patient in the patient compartment at all times; and (B) When an ambulance service provides advanced life support care under its protocols, the patient shall be attended by an EMT-Paramedic, registered nurse, or physician. (5) Each ambulance service shall maintain accurate records and forms on the following: (A) An ambulance report to record information on each emergency request for service and each ambulance run; (B) Ground ambulance service license; (C) Medical director protocol and policy authorization; (D) Vehicle maintenance records; (E) Vehicle driver education records; (F) Equipment maintenance records; and (G) Records required by other regulatory agencies. (6) Each ambulance service shall have a medical control plan that has been approved by their medical director and service manager. The medical control plan is that portion of the medical protocols which specifically addresses the transfer of patient care between agencies. (7) Each ambulance service that provides advanced life support services, basic life support services utilizing medications (medications include activated charcoal, oral glucose and/or oxygen) or providing assistance with patients’ medications (patient medications include a prescribed inhaler, nitroglycerin and/or epinephrine), or basic life support services performing invasive procedures including invasive airway procedures (invasive airway procedures include esophageal or endotracheal intubation) shall have a designated medical director, working under an agreement, who is trained and meets the requirements for a medical director in accordance with 19 CSR 30-40.303. (8) Each vehicle operated as an ambulance shall have the capability to communicate by voice with local hospital(s), trauma centers, and the service’s own dispatching agency. (9) There shall be an ongoing quality improvement program designed to objectively and systematically monitor, review, and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care and resolve identified problems. (10) Each ambulance service shall maintain policies and procedures that include the following: (A) Safety program, including infection control program; (B) Vehicle operations and driving procedures; (C) Communications procedures; (D) Ambulance operations procedures; (E) Standards for clinical care (medical protocols); (F) Vehicle and equipment maintenance; (G) Disaster/multiple casualty protocols; and (H) Quality improvement program. (11) Each ambulance service shall display a copy of their ambulance service license in the patient care compartment of each ambulance vehicle operated by the ambulance service. (12) Each ambulance service that held a valid ambulance vehicle license on August 28, 1998, and meets all the legislative and regulatory requirements for licensure shall be issued an initial license for a period of one to five (1–5) years. The Bureau of EMS will determine the initial licensure period for each ambulance service by randomly selecting an equal number of ambulance services for each of the five (5) periods of licensure based on the date the application is received by the Bureau of (13) An existing ambulance service licensee may apply for and be granted by Bureau of EMS a reduction in their primary service area if they meet the following requirements: (A) Submit a completed application for licensure, requesting a reduction of their ambulance service area and include a detailed description of the affected area that will no longer be included in their primary service area; and (B) Provide written documentation of an agreement with another licensed ambulance service, stating the service has agreed to provide ambulance service to the vacated service area through an expansion of their services, by either contract or mutual aid agreement or provide public notice to residents of the affected area. 1. Public notice to residents of the affected area includes: A. Publishing notice in a newspaper of the largest general circulation, that is published in the county in the area affected by the decision to withdraw ambulance coverage, a minimum of one (1) year in advance of the proposed date of discontinuation of ambulance services. A completed affidavit of publication and an original clipping of published notice must accompany the application for licensure; and B. Providing written notice to the county commission of any county that as a whole or in part, will be affected by the discontinuation of services, a minimum of one (1) year in advance of the proposed date of discontinuation of ambulance services. AUTHORITY: sections 190.109, 190.176, 190.185, and 190.190, RSMo 2016.* Emergency rule filed Aug. 28, 1998, effective Sept. 7, 1998, expired March 5, 1999. Original rule filed Sept. 1, 1998, effective Feb. 28, 1999. Emergency amendment filed March 31, 2003, effective April 14, 2003, expired Oct. 11, 2003. Amended: Filed March 31, 2003, effective Sept. 30, 2003. Emergency amendment filed March 16, 2017, effective March 26, 2017, expired Jan. 3, 2018. Amended: Filed March 16, 2017, effective Nov. 30, 2017. ** *Original authority: 190.109, RSMo 1998, amended 2001, 2002; 190.176, RSMo 1998, amended 2008, 2011; 190.185, RSMo 1973, amended 1989, 1993, 1995, 1998, 2002; and 190.190, RSMo 1973, amended 1998. **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30-40.309, subsection (2)(B) and section 190.243.4, RSMo was suspended from March 19, 2020 through June 15, 2020 and subsections (1)(A), (1)(C), and (1)(D) was suspended from April 29, 2020 through June 15, 2020.