[30 Pa.B. 5363]
[Continued from previous Web Page] Comment
This section states that ''ambulance services located or headquartered outside of this Commonwealth that regularly engages in the business of providing emergency medical care and transportation of patients from within this Commonwealth . . .'' are required to be inspected and licensed by the Department. First, the word ''engages'' should be ''engage.'' Second, the term ''regularly'' is vague. The Department should explain whether all out-of-state providers that provide service in this Commonwealth are required to be inspected and licensed by the Department.
Response
The Department agrees with that part of the comment questioning use of the word ''engages.'' It has replaced ''engages'' with ''engage.''
As to the second part of the comment, section 12(t)(3) of the EMS act permits some ambulance services that are located or headquartered outside this Commonwealth to engage in limited operations in this Commonwealth without securing a license from the Department. The statutory provision is written in a confusing manner, but as the Department interprets it, that provision permits an ambulance service located or headquartered outside of this Commonwealth to operate within this Commonwealth without a license issued by the Department only if it is transporting patients from locations outside of this Commonwealth to locations within this Commonwealth. The Department has added a sentence to clarify this. Moreover, the exemption is extended only if the transports do not occur ''routinely.'' Under section 6 of the EMS act, operation of an ambulance service without a license is a summary offense. The Department proposed to use the word ''regularly'' rather than ''routinely'' because it believed that persons would understand that term better. However, as the courts, not the Department, make summary offense determinations, the Department has reconsidered replacing the term ''routinely'' with ''regularly,'' and has reinserted the term that is employed in the statute.
Section 1005.7 (relating to services owned and operated by hospitals) reiterates provisions in section 12(r) of the EMS act (35 P. S. § 6932(r)) which permit institutions licensed as hospitals by the Department to operate their own ambulance service without securing a separate license from the Department to operate an ambulance service. In all other matters, the ambulance service operations of hospitals are subject to the EMS act and this part. No comments addressing this section were received. This section is adopted as proposed.
Section 1005.7a (relating to renewal of ambulance service license) is new. It explains that the criteria for the renewal of a license are the same as the criteria for securing an initial license if an initial license had been sought at the time the renewal was required. A time period for filing a renewal application prior to the expiration of a current license is specified. No comments addressing this section were received. This section is adopted as proposed.
Section 1005.8 pertains to the license the Department is permitted to issue to an ambulance service when it fails to meet multiple minor licensure requirements, or even a significant requirement, if the Department considers the operation of the ambulance service to be in the public interest. Section 12(m) of the EMS act permits the Department to issue a provisional license for 6 months and to renew it for an additional 6 months under regulations established by the Department, except a renewal may be for 12 months if the ambulance service is a volunteer BLS ambulance service, or a volunteer fire department or rescue service that operates a BLS ambulance service.
Comment
The EMS act and these regulations provide that if a BLS ambulance service is a volunteer ambulance service the Department may renew a provisional license for 12 months. Nowhere in the EMS act or in the regulations is a ''volunteer ambulance service'' defined. The regulations should define the term.
Response
The Department agrees with this comment. As previously discussed in reviewing the revisions to proposed § 1001.2, the Department has added a definition for ''volunteer ambulance service.''
Other Change
As will be discussed under § 1005.10 (relating to licensure and general operating standards), the Department has revised its proposed regulations to permit an ambulance service to maintain a duty roster or a staff availability schedule. This section has been revised to provide that the Department will require an ambulance service to maintain a duty roster if it issues the ambulance service a provisional license because of its failure to meet staffing standards or to apprise PSAPs when it is unable to respond to an emergency. This change was recommended by PEHSC after it reviewed the Department's change to proposed rulemaking to allow ambulance services to maintain a staff availability schedule instead of a duty roster.
Section 1005.9 (relating to temporary license) pertains to the license that the Department is permitted to issue to an ALS ambulance service that cannot provide service 24 hours-a-day, 7 days-a-week. No comments addressing this section were received.
Change
This section has been revised to provide that the Department will require an ambulance service to maintain a duty roster if it issues the ambulance service a temporary license. As in § 1005.8, this change was recommended by PEHSC after it reviewed the Department's change to proposed rulemaking to allow ambulance services to maintain a staff availability schedule instead of a duty roster.
Section 1005.10 is the section that enumerates most of the standards an ambulance service needs to meet to become licensed and to continue operations.
Comment
Proposed subsection (a)(1) would require the ambulance service to document its process for scheduling staff to ensure that the minimum staffing requirements proposed in subsection (d) are met. Proposed subsection (d)(1)(iii) would specify that minimum staffing standards are satisfied when an ambulance service has a duty roster that identifies staff who meet the minimum staffing criteria who have committed themselves to be available at the specified times, and when the required staff are present during the emergency medical treatment and transport of a patient. Volunteer services may not be able to meet a ''duty roster'' requirement that requires staff to ''commit'' to being available at specified times. If adequate service is being provided, the Department should either use an outcome or performance standard, or explain why volunteers should be required to make specific commitments.
Response
The Department will not rely solely on performance, but has revised the proposed requirement for a duty roster to permit the ambulance service to have a staff availability schedule instead of a duty roster.
The types and number of prehospital personnel who must be present during the emergency medical treatment and transport of a patient are specified by statute. See 35 P. S. § 6932(e)(4) and (g)(1)(i)--(iv) and (2)(ii). Ambulance services are required to be able to meet these requirements whenever they are in operation. ALS ambulance services are expressly required to operate 24 hours-a-day, 7 days-a-week. See 35 P. S. § 6932(n).
In addition to monitoring ambulance service operations to ensure that they are meeting staffing requirements, the Department is required to determine whether an ambulance service will be able to meet staffing requirements before it issues or renews an ambulance service license. See 35 P. S. § 6932(h)(3). If the Department were to rely solely on performance, it would not be satisfying its responsibility to reasonably assure itself, before it issues a license, that staffing standards will be met.
In determining whether an applicant for licensure will meet staffing standards, the Department can look at the roster of personnel included with the application, but to conclude that staffing standards will be met during operation of the ambulance service the Department needs to ensure that the ambulance service has a mechanism in place to identify occasions when it will clearly not be able to meet staffing standards. This is particularly important, so that PSAPs may be properly alerted.
Requiring an ambulance service to maintain a duty roster was the Department's proposed solution, but the Department has been convinced by the comments it has received that prehospital personnel, particularly volunteers, will have a discomfort in making duty commitments for fear of liability should they not be able to honor their commitments. Consequently, the Department has included, as an alternative to the proposed duty roster requirement, a requirement that the ambulance service keep a listing of prehospital personnel who have been assigned to work by the ambulance service, if that has occurred, augmented by a listing of prehospital personnel who believe they will be available to respond if called. In essence, this will result in the exclusion of names of only those persons who know they are not available. If the ambulance service maintains a duty roster or a staff availability schedule it will know, or at least have a reason to believe, when it will not able to fill a time slot with appropriate crew. It can then provide advance notice to the dispatcher. Notwithstanding this change, the Department encourages ambulance services to maintain duty rosters if feasible. The Department expects that most large ambulance services will maintain a duty roster.
If the Department relies solely on outcomes and performances, not only will it not be satisfying its statutory duty to ensure that ambulances will be staffed as required, it also will not be dealing with a staffing problem prospectively. The two most frequent problems presented by ambulance services are failure to respond to an emergency call because they cannot secure a sufficient number of appropriate staff to respond to a call, and treating and transporting a patient without a proper crew. The ambulance services that most often experience these problems are small nonprofit ambulance services whose members are all or mostly volunteers. Maintaining a staff availability schedule or a duty roster will help these services, in particular, to identify staffing inadequacies. When an ambulance service identifies inadequate staff through one of these tools, it will be responsible for notifying a PSAP. While PSAPs have procedures for contacting backup ambulance services or QRSs when the first ambulance service they call cannot respond, precious time is lost if dispatchers need to resort to a backup after making an unfruitful call.
If the Department or a regional EMS council sees that an ambulance service is not able to assign or otherwise have crew available for certain times, it can work with the ambulance service on a timely basis to help it improve its capacity to respond as required by statute. As made clear in section 12(m)--(o) of the EMS act, the legislative preference is that the Department work with ambulance services to resolve staffing and manpower problems before resorting to imposing sanctions, including the possible revocation of a license due to the ambulance service not satisfying staffing requirements. Subsections (a)(1) and (d)(1)(iii) provide ambulance services and the Department with tools to help them identify and address manpower and staffing problems when those problems are in their infancy.
Comment
When issuing a license what formula will the Department use to determine whether the ambulance service will meet minimum staffing requirements?
Response
There is no formula. The ambulance service needs to have commitments from several prehospital personnel to ensure that it has an adequate number of personnel to respond. For BLS ambulance services, a number of those personnel must be certified at least at the level of EMT, and for ALS ambulance services a number of those personnel must be certified at least at the level of EMT-paramedic. If the number is so small that there is a question of whether there will be sufficient numbers and types of personnel to fill all time slots, inquiries may be made regarding the flexibility of work hours of those persons who have been identified, and the applicant may be requested to develop a model staffing schedule after consulting with personnel who have made commitments to it. Inquiries may also be made about current recruiting efforts. If the Department is not convinced that staffing standards will be satisfied, it may offer to issue the applicant a provisional or temporary license. If the applicant refuses that offer, and elects to pursue its license application, it would be entitled to a hearing on whether it will meet the staffing requirements for licensure. The applicant would have the burden of proof.
Comment
If an ambulance service is required to have personnel ''committed'' to be available to respond to calls at certain times, this may trigger the minimum wage and overtime provisions of the Fair Labor Standards Act (29 U.S.C.A. §§ 201--219). This would impose a significant expense to many licensees.
Response
This issue has become moot due to the Department revising the regulation to provide an ambulance service with the alternatives of maintaining a duty roster or a staff availability schedule.
Comment
If an ambulance service operates more than one ambulance, it should not be required to meet the minimum staffing standards for each ambulance it maintains.
Response
An ambulance service is not required to have a separate staff availability schedule for different ambulances it operates in the same service area. An ALS ambulance service, for example, need only operate one ambulance in a service area to meet the express statutory requirement that it operate 24 hours-a-day, 7 days-a-week. However, an ALS ambulance service needs to be able to operate at least one ambulance at all times in each service area where it conducts business. Moreover, each ambulance an ambulance service operates needs to be properly staffed, as prescribed by the EMS act, when it being used.
Comment
Remove from proposed subsection (a)(3) the requirement that an ambulance service shall maintain a record of each call it received to which it was unable to respond, and the reason it was unable to respond. A record of the ambulance service's failure to respond should be maintained by the dispatching communications center.
Response
The Department does not regulate PSAPs and, therefore, cannot impose requirements on them. Also, while PSAPs may maintain records of when an ambulance service is unable to respond, it may not receive or maintain a record of the reason for each lack of response. By the ambulance service maintaining this record, the Department and regional EMS councils will be able to identify problems in the EMS system and work with ambulance services to address those problems.
Comment
The proposed deletion in subsection (e) of provisions relating to mutual aid agreements seems to grant PSAPs the authority to dispatch whichever ambulance services they choose. This section should be amended to provide that control over which ambulance services are to be dispatched rests with local government and that the role of the dispatching office is to dispatch in accordance with the plan of a municipality.
Response
The repeal of the prior text of subsection (e) confers no power on PSAPs. The Department neither regulates nor empowers PSAPs. But the Department does recognize that PSAPs are the bodies that dispatch ambulance services, regardless of whether PSAPs have the authority to make dispatch decisions or to merely implement dispatch protocols that have been prescribed by some other entity. The repeal of the previous provisions in subsection (e) does not preclude ambulance services from entering into mutual aid agreements. Ambulance services may continue to have mutual aid agreements with other ambulance services, but they may not use those agreements in an attempt to dictate to PSAPs which ambulance service to dispatch on a second call basis when a party to the agreement is dispatched first but is unable to respond to the call. As stated previously, the Department anticipates that ambulance service dispatch legislation will soon be enacted. The Department expects that particular legislation will establish a statutory scheme for the development and implementation of ambulance service dispatch protocols.
Comment
Proposed subsection (e)(2) requires an ambulance service to apprise the PSAP, as soon as practical after receiving a dispatch call, if it is not able to have an ambulance and required staff immediately en route to an emergency. What does the term ''immediately'' mean? A fail time of 5 minutes should be used.
Response
The Department agrees that the term ''immediately'' is not appropriate. PSAPs in different parts of this Commonwealth will have different preferences as to how much time should elapse after dispatch before an ambulance service does not have an ambulance en route to an emergency, such that an ambulance service's knowledge that it can not satisfy that standard triggers a duty to report to the PSAP. In a metropolitan area with a large number of ambulance services in a concentrated area, the PSAP may have viable dispatch alternatives if the delay is more than a few minutes. In a sparsely populated rural area viable alternatives may not exist unless the delay is substantial. Consequently, the Department has revised subsection (e)(2) to provide that the duty to apprise the PSAP about not having an ambulance en route to an emergency after dispatch is triggered when an ambulance service realizes it will not have an ambulance en route to an emergency within the time prescribed by the PSAP to require a notification to the PSAP.
Comment
Proposed subsection (e)(4) would require an ambulance service to respond to an emergency when dispatched by a PSAP. An ambulance service should not have its license jeopardized if it is occupied with another call or if it intends to function solely as an interfacility transport service.
Response
The Department agrees that an ambulance service should not be subject to disciplinary action if it fails to respond to an emergency call because it is occupied with another call. The focus of the Department when proposing this paragraph was to establish a procedure to resolve conflicts between two competing ambulance services when both believe it is the most appropriate service to respond to a call. Over the last few years, physical conflicts between prehospital personnel from different ambulance services have actually erupted on occasion around which ambulance service should be transporting a patient to a receiving facility. In an EMS system, the PSAP needs to direct ambulance service response when there is a dispute. If the proposed ambulance service dispatch legislation is enacted, in making the decision as to which ambulance service shall handle the emergency, the PSAP will simply be following a dispatch protocol that has been developed under statutorily prescribed procedures.
As to ambulance services that choose to confine their activities to interfacility transports, the Department believes that there is no likelihood that any dispatch protocol will be developed that designates these services as primary emergency responders. However, these services are part of the EMS system and must be prepared to respond to emergencies when needed. In mass casualty situations they may very well be dispatched to emergency calls. Nevertheless, to clarify the intent of this provision as it applies to both ambulance services that generally respond to emergency calls and ambulance services that generally confine their business to interfacility transports, the Department has revised the proposal to state that the duty to follow the direction of the dispatcher applies only when the ambulance service is able to respond (that is, it has resources available, such as an ambulance, crew, equipment and supplies, that enable it to respond.)
Comment
While the effort made in proposed subsection (g) to tighten the requirements for the use of lights and sirens should be applauded, a better approach would be to prohibit the use of lights and sirens unless the circumstances result in a need for immediate medical intervention that exceeds the capabilities of the ambulance crew.
Response
The Department accepts the recommendation and has revised this subsection accordingly.
Comment
Subsection (g) should be revised to include PEHSC recommendations regarding the use of lights and sirens by ambulance services.
Response
The regulation is consistent with the PEHSC recommendation. Both provide that lights and sirens are to be used only when responding to or transporting a patient with a life-threatening or potentially life-threatening condition.
Comment
Proposed subsection (i) should be clarified whether it requires reporting of only those accidents and injuries to individuals that result from or are associated with an ambulance vehicle accident.
Response
Subsection (i) requires that ambulance services report ambulance vehicle accidents that are reportable under 75 Pa.C.S. (relating to Vehicle Code) and all line of duty fatalities and injuries that required treatment at a hospital, whether from ambulance crashes or other incidents.
Comment
Injury reporting under proposed subsection (i) could become very cumbersome. The proposed reporting requirement should be revised to require the report of severe injuries only, and define what a severe injury is.
Response
The recommendation is rejected. By requiring the reporting of only those injuries that are treated in a hospital, the burden to ambulance services should be minimal. These reports will enable the Department to gather data regarding the incidence, type and severity of injuries sustained in providing EMS. The Department, with the assistance of PEHSC and the regional EMS councils, will be able to use this information to alert ambulance services to potential hazards, and to develop prevention and risk management guidelines to disseminate to providers of EMS and EMS training institutes.
Comment
Requiring all ALS ambulances to have guaranteed staffing 24 hours-a-day, 7 days-a-week would require all volunteer ALS ambulance services to convert to paying prehospital practitioners and eliminating the volunteer system. There should be no strict Statewide standards on staffing. Let municipalities, working with the appropriate regional EMS council, establish the staffing standards within their borders.
Response
This recommendation is rejected. Statewide standards are imposed by the EMS act. The Department has no authority to promulgate regulations providing otherwise. Section 12(g) of the EMS act prescribes minimum staffing standards for ALS ambulance services on a Statewide basis. Section 12(n) of the EMS act requires an ALS to provide service 24 hours-a-day, 7 days-a-week to maintain full licensure.
Other Changes
One of the criteria an entity needs to meet to be licensed as an ambulance service is that it be staffed by responsible persons. See 35 P. S. § 6932(h)(1). Neither the EMS act nor Part VII have heretofore identified the persons to whom the ''responsible'' standard applies. The Department has revised subsection (d) by adding paragraph (3) to address this matter. Subsection (d)(3) clarifies that the ''responsible'' standard applies to the management team, prehospital personnel and ambulance drivers. It requires the ambulance service to ensure that it is staffed by responsible persons, and directs the ambulance service to collect and consider the criminal and disciplinary records of its staff in making that determination. It also requires the ambulance service to provide the Department with 30 days advance notice, if possible, if it makes a change in its management team that includes the addition of a person who has a criminal or disciplinary record. This last provision will enable the Department to monitor management changes and to take appropriate action if a licensed ambulance service seeks to employ management personnel who present the greatest potential for being determined by the Department not to be responsible persons.
Subsection (a)(1) is revised to require the ambulance service to maintain a record of persons who function as its management team, and to maintain the disciplinary and criminal history record of all persons who staff the ambulance service. Subsection (k), which pertains to the ambulance service's monitoring responsibilities, requires the ambulance service to apprise the Department if it determines that a prehospital practitioner who is part of its staff has engaged in conduct for which the Department may impose discipline.
Section 12(i) of the EMS act prohibits the transfer of an ambulance service license. Section 12(l)(6) of theEMS act makes the lending, borrowing or using of another's license a basis for disciplinary action against an ambulance service. Over the last few years there has been an increasing use of management services by ambulance services to help them manage their operations. This is acceptable, provided that the management service does not make fundamental operating decisions for the ambulance service. The Department needs to be able to review management agreements and ask questions of the ambulance service to ensure that the arrangement is not a de facto lending or permitting use of an ambulance service license by an entity not licensed as an ambulance service. Consequently, the Department has added subsection (a)(6) to require an ambulance service to maintain in its records a copy of any management agreement it has entered into to either manage an ambulance service or be managed by another entity.
There have been questions about acceptable and required identifications on ambulance services. Subsection (b) pertains to ambulance standards. The Federal KKK standards address, among other matters, star of life markings on ambulances that operate as mobile ALS care units. Those standards do not apply to ambulances that operate as squad units. The Department has redesignated the text of proposed subsection (b) as paragraph (1) and has added a paragraph (2) to address the placement of names on ambulances and the placement of star of life markings on squad units.
Proposed subsection (c)(3) has been revised to provide improved clarity.
Subsection (d)(1)(i) has been revised to incorporate the statutory standard regarding when a BLS ambulance needs to meet minimum staffing standards.
Subsection (d)(1)(iii) has been revised to include the proposed text in clause (A) and to include in clause (B) language requiring an ambulance service to comply with child labor law statutes and regulations when using persons 18 years of age or younger to staff the service.
In subsection (d)(2) the term ''ALS medical director'' has been corrected to read ''ALS service medical director.''
Subsection (g), which pertains to the use of lights and other warning devices, is revised to clarify that compliance with the standards in that subsection does not excuse noncompliance with standards imposed by the Vehicle Code.
Subsection (l) is amended to add a policy on substance abuse in the workplace as one of the policies that an ambulance service must have.
Section 1005.11 (relating to drug use, control and security) addresses the circumstances under which ambulance services may stock and carry drugs, drugs that may be used, requirements for securing and maintaining those drugs, and who may administer such drugs.
Comment
Proposed subsection (a)(3) mentions drugs being carried on board an ambulance by a physician assistant. The status of the physician assistant in the EMS system should be clarified.
Response
Physician assistants are not regulated under the EMS act. They do not function as prehospital personnel for ambulance services. However, the Department recognizes that nurses and physician assistants with special training may be attending to a patient in a hospital setting and that the hospital may want them to accompany the patient and continue to address certain patient care needs during an interfacility transport. Subsection (a)(3) provides for a physician assistant to bring drugs on board an ambulance only when the ambulance is engaged in an interfacility transport, the physician assistant has special training for the continuation of treatment that had been provided to the patient at the facility from which the patient is being transferred, and the physician assistant does not substitute for staff required by the EMS act.
Comment
Proposed subsection (d)(2) permits a health professional to administer drugs in addition to those permitted by the applicable regional and Statewide medical treatment protocols. Does this open the door for prehospital registered nurses to operate in the EMS system on an unregulated basis?
Response
There are sufficient controls to ensure that the prehospital registered nurse functions within the parameters of the EMS system. This paragraph requires that the health professional's use of additional drugs be approved by the ALS service medical director for the ambulance service and then specifically ordered by a medical command physician.
Comment
Current subsections (j) and (k) are not consistent with current practice when drugs that are used are replaced through medication orders rather than prescriptions. These subsections should be revised to reflect current acceptable practices.
Response
The person who made this comment was apparently confused by the proposed amendments to this section. The Department proposed to remove subsections (j) and (k), and to address the subject matter previously addressed in those subsections in new subsection (e). Subsection (e)(5) requires the ambulance service that seeks to replace a drug to provide the dispensing hospital, physician or pharmacy with a written record of the use, loss or other disposition of the drug. When a drug's disposition occurs through administration of the drug to the patient, as opposed to another disposition, such as breakage or theft, the EMS patient care report will suffice as the requisite written record.
Changes
The language in subsection (b) is revised to improve clarity.
A new paragraph (7) is added to subsection (d) to require an ambulance service to ensure that the disposal of drugs occurs in compliance with the requirements of The Controlled Substance, Drug, Device and Cosmetic Act (35 P. S. §§ 780-101--780-149), and proposed subsection (d)(7) is now subsection (d)(8).
Section 1005.12 (relating to disciplinary and corrective actions) pertains to the disciplinary process applicable to ambulance services. The title of this section is changed from ''Grounds for suspension, revocation or refusal of an ambulance service license'' because the scope of this section exceeds the enumeration of grounds for discipline.
Comment
Proposed subsection (a)(9) would establish that failure of an ALS ambulance service to have staff sufficient to operate an ambulance 24 hours-a-day, 7 days-a-week, is a ground for discipline against an ALS ambulance service. This ground should be revised so that it applies to BLS ambulance services also.
Response
This recommendation is rejected. Following the recommendation would require the Department to exceed the scope of its rulemaking authority. The criteria for licensure of an ambulance service under section 12(h) of the EMS act does not include operation of an ambulance around-the-clock. That requirement is made applicable to ALS ambulance services under section 12(n) of the EMS act, which provides that an ALS ambulance service could operate under a temporary license if it fails to meet that standard. No similar provision links a BLS ambulance service to an around-the-clock operational standard. Nevertheless, under § 1005.10(e) a BLS ambulance service that provides emergency response is required to apprise a PSAP when it will not be in operation.
Other Changes
A new paragraph (19) is added in subsection (a) to include as a basis for discipline the failure of an ambulance service to continue to meet the standards it was required to satisfy when it secured a license.
Section 1005.13 (relating to removal of ambulances from operation) pertains to the removal of an ambulance from operation when there is a mechanical or equipment deficiency that poses a significant threat to the safety of patients or crew. No comments on this section were received, however the Department has revised the language to provide greater clarity.
Section 1005.14 (relating to invalid coaches) pertains to a statutory exemption from ambulance requirements for vehicles that are used to transport individuals who require assistance, but who are not anticipated to require emergency medical care during transport. No comments on this section were received. This section is revised to eliminate reference to § 1001.2 for the definition of ''invalid coach,'' as no similar reference is made in other regulations for terms defined in § 1001.2.
Section 1005.15 is new. It addresses and clarifies the duty imposed upon an ambulance service, by section 12(q) of the EMS act, to not discontinue its operations prior to giving the public, the Department and political subdivisions in its service area at least 90 days advance notice. The regulation also requires the ambulance service to provide similar notice to emergency communications centers in the EMS region in which it would be ceasing operations.
Comment
Although the proposed section is consistent with section 12(q) of the EMS act, the statutory provision is probably unconstitutional in that it forces an entity to stay in business without just compensation.
Response
The Department must assume that the referenced statutory provision is constitutional. The regulation is adopted as proposed.
Chapter 1007. Licensing of Air Ambulance Services-Rotorcraft
This chapter specifies the licensure and operating criteria for air ambulance services. Several provisions in Chapter 1005 that are applicable to ground ambulance services are equally applicable to air ambulance services. Express provision is made in this chapter to incorporate applicable provisions in Chapter 1005. Consequently, some of the prior sections in this chapter are not needed. They have been repealed.
Section 1007.1 (relating to general provisions) specifies general standards applicable to air ambulance services. The most significant amendment of this regulation is the addition of subsection (e). This subsection specifies sections in Chapter 1005 that apply to air ambulance services as well as ground ALS ambulance services.
All air ambulance services are licensed to provide ALS care. Some of the sections that are referenced in subsection (e) impose different requirements upon a ground ambulance service depending upon whether the service is licensed to provide ALS care or only BLS care. This subsection clarifies that the provisions of those sections that apply to air ambulance services are those which also apply to ground ALS ambulance services.
Comment
Air ambulance services are not addressed by the EMS act. This chapter should be deleted.
Response
The recommendation is rejected. The EMS act requires the Department to license and regulate entities that use ambulances to provide EMS to patients. The statutory definition of ''ambulance'' does not confine the described vehicle to a ground vehicle.
Changes
The proposed language the Department submitted to the LRB for subsection (e) was different than the actual language published. The Department's proposal related that only those provisions in the Chapter 1005 sections referenced in subsection (e), that apply to ground ALS ambulance services, are applicable to air ambulance services. The LRB exercised its editorial prerogative to revise the proposed language in a nonsubstantive manner. However, the LRB or its contract printer made errors in printing the revised language, causing it to read that all provisions in the referenced sections would be applicable to air ambulance services. The Department has corrected the error. The Department has also added § 1005.2a (relating to change in ambulance fleet) to the list of sections in Chapter 1005 that apply to air ambulance services.
Section 1007.2 (relating to applications) specifies the information solicited by applications for air ambulance service licenses. No comments on this section were received.
Changes
Consistent with its addition of § 1005.2(a)(10), to provide that the license application for a ground ambulance service will solicit specified information regarding the management team, the Department has added a similar provision in subsection (a)(10) and has renumbered proposed subsection (a)(10) as subsection (a)(11).
Procedures for an entity to apply for a license as an air ambulance service, for an air ambulance service to apply for an amendment of its license, and for regional EMS councils to process those applications are the same as those that are applicable to ground ambulance services. The Department had proposed new subsections (b)--(d) to cover this subject matter. However, it has elected to replace the proposed text of these subsections with a revised subsection (b). That subsection states that the procedures for making the applications and for regional EMS councils to process the applications are the same as those that are applicable to ground ambulance services.
As proposed, §§ 1007.3--1007.6 are repealed. Most of the subject matter that was addressed in these sections duplicated provisions in Chapter 1005. Section 1007.1(e) makes those provisions applicable to air ambulance services.
Section 1007.7 (relating to licensure and general operating requirements) enumerates most of the standards an entity needs to meet to become licensed as an air ambulance service and to continue operations. No comments addressing this section were received.
Changes
Subsection (a) is revised to require the air ambulance service to maintain the same type of information on medical command authorization and persons managing the air ambulance service that is required of a ground ambulance service under § 1005.10(a)(1). Subsection (a)(2) is revised by replacing ''ambulance call report'' with ''EMS patient care report.''
Subsection (b)(7) is revised to reflect that survival gear carried on an air ambulance shall be determined on a flight-by-flight basis.
Subsection (d)(3)(iii) is revised to require the air ambulance service to maintain a duty roster. No provision for a ''staff availability schedule,'' as an alternative to a duty roster, is required for an air ambulance service.
Subsection (d)(4) is added to require an air ambulance service to collect the same type of information regarding its staff as a ground ambulance service and to consider that information in making determinations as to whether its staff is comprised of responsible persons.
Subsection (f)(2) is revised to insert the word ''service's'' before ''service area.''
Subsection (g)(1) is revised to include air ambulance availability as an additional criterion in making a decision regarding whether to respond to a call.
Subsection (h) is revised by adding to the medical service requirements of an air ambulance service the requirement that the air ambulance service shall ensure that the patient is transported to the nearest appropriate receiving facility. Air ambulances may travel great distances to pick up an emergency patient. An equally long return trip is not in the best interest of the patient if appropriate care for the patient can be achieved by the air ambulance making a shorter patient transport trip. The Department does not consider it appropriate for an air ambulance to transport a patient to a trauma center affiliated with the entity that operates the air ambulance service if a trauma center appropriate for the care of the patient is located much closer to the location where the patient is retrieved. Considerations such as weather conditions, and patient choice when additional travel time will not impact the patient's condition, may justify bypassing a closer trauma center but, in most instances, these considerations do not come in to play.
Subsection (k)(1) is revised to substitute the words ''air medical'' for ''aeromedical.''
Subsection (m) is revised to add, to an air ambulance service's monitoring duties, responsibilities similar to those that are being imposed upon ground ambulance services.
Subsection (n) is revised to include a policy on substance abuse in the workplace as a policy an air ambulance service is required to maintain.
Section 1007.8 (relating to disciplinary and corrective actions) deals with the disciplinary process applicable to air ambulance services. No comments addressing this section were received.
Changes
A new paragraph (22) is added in subsection (a) to include as a basis for discipline the failure of an air ambulance service to continue to meet the standards it was required to satisfy when it secured a license.
As proposed, § 1007.9 (relating to voluntary discontinuation of service) is repealed. This section addressed the duty imposed upon an air ambulance service, under section 12(q) of the EMS act, to not discontinue its operations prior to giving advance notice to the Department, political subdivisions in its service area, and the public. This subject matter is addressed in § 1005.15 (relating to discontinuance of service). Section 1007.1(e) makes § 1005.15 applicable to air ambulance services.
Chapter 1009. Medical Command Facilities
This chapter deals with the distinct units in hospitals out of which physicians who qualify as medical command physicians provide medical direction to prehospital personnel. Medical direction is provided when prehospital personnel are providing emergency medical care in prehospital settings and during the interfacility transport of patients.
Section 1009.1 (relating to operational criteria) sets forth the requirements that must be met for a distinct unit in a hospital to function as a medical command facility.
Comment
Proposed paragraph (12) should be revised to prescribe a standard length of time a medical command facility needs to keep communication records and tapes.
Response
The Department agrees with this comment. It has revised paragraph (12) to require a medical command facility to maintain medical command tapes for 180 days. This should assure the availability of these tapes for a period of time adequate to enable their use in quality improvement reviews and disciplinary investigations.
Comment
Contrary to proposed paragraph (15), medical command facilities should not be required to provide medical command to a prehospital practitioner with whom the facility is not familiar.
Response
This recommendation was previously discussed under § 1003.4. It is rejected for the reasons explained in responding to the recommendation under that section.
Section 1009.2 (relating to recognition process) describes the procedure to be followed if a facility chooses to be recognized as a medical command facility by the Department.
Comment
While it is true that section 11(j)(4) of the EMS act (35 P. S. § 6931(j)(4)) provides that a medical command facility will enjoy certain civil liability protection under that provision if it is recognized by the Department, the Department should remove reference to that fact to give some leeway to assert statutory immunity by a hospital that may substantially comply with the regulation but has not gone through the recognition process.
Response
This recommendation is rejected. The EMS act requires that a facility be recognized as a medical command facility by the Department for a facility to secure the civil immunity protection afforded by section 11(j)(4) of the EMS act. The Department is not aware of any hospital that has operated in this Commonwealth as a medical command facility without completing the Department's recognition program. Nevertheless, the Department believes that including language in this regulation which apprises a hospital that Department recognition of its medical command operations as a medical command facility affords it some civil immunity protection, serves as a helpful reminder to hospitals regarding what they need to do to limit their exposure to liability. It is the Department's experience that some facilities are more familiar with the Department's regulations than they are with the EMS act. Moreover, the questioned provision explains the statutory basis for the Department to operate a medical command facility recognition program.
No other comments addressing this section were received, other than mention of a typographical error in subsection (a) that appeared in the Pennsylvania Bulletin when the proposed regulations were published. This section is adopted as proposed. The typographical error has been corrected.
Section 1009.3 (relating to continuity of medical command) is repealed. This regulation grandfathered medical command facilities recognized by regional EMS councils prior to July 1, 1989, the date this former regulation was promulgated. The regulation is no longer required.
Section 1009.4 (relating to withdrawal of medical command facility recognition) identifies the procedures for conducting inspections and investigating complaints against medical command facilities, the grounds for withdrawal of recognition and procedures for dealing with deficiencies in lieu of withdrawing recognition. No comments addressing this section were received. This section is adopted as proposed.
Section 1009.5 (relating to review of medical command facilities) provides for regional EMS councils to conduct reviews of medical command facilities.
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