Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 51 Pa.B. 3586 (June 26, 2021).

28 Pa. Code § 1023.1. EMS agency medical director.

§ 1023.1. EMS agency medical director.

 (a)  Roles and responsibilities. An EMS agency medical director is responsible for:

   (1)  Providing medical guidance and advice to the EMS agency, including:

     (i)   Reviewing the Statewide EMS protocols and Department-approved regional EMS protocols that are applicable to the EMS agency and ensuring that its EMS providers and other relevant personnel are familiar with the protocols applicable to the EMS agency.

     (ii)   Performing medical audits of EMS provided by the EMS agency’s EMS providers.

     (iii)   Participating in and reviewing quality improvement and peer reviews of EMS provided by the EMS agency.

     (iv)   Reviewing regional mass casualty and disaster plans and providing guidance to the EMS agency regarding its provision of EMS under those plans.

     (v)   Providing guidance to the EMS agency, when applicable, with respect to the ordering, stocking and replacement of medications, and compliance with laws and regulations impacting upon the EMS agency’s acquisition, storage and use of those medications.

     (vi)   Making an initial assessment of each EMS provider at or above the AEMT level to determine whether the EMS provider has the knowledge and skills to competently perform the skills within the EMS provider’s scope of practice, and a commitment to adequately perform other functions relevant to the EMS provider providing EMS at that level. This subparagraph does not apply if the EMS provider was working for the EMS agency at the same level prior to the physician becoming the medical director for the EMS agency and the EMS provider was credentialed at that EMS agency within the last 12 calendar months as being able to perform at the EMS provider’s certification level.

     (vii)   Making an assessment, within 12 calendar months of the last assessment, of each EMS provider at or above the AEMT level to determine whether the EMS provider has demonstrated competency in the knowledge and skills to perform the skills within the EMS provider’s scope of practice, and a commitment to adequately perform other functions relevant to the EMS provider providing EMS at that level.

     (viii)   Recommending to the EMS agency that an EMS provider not be permitted to provide EMS at the EMS provider’s certification level if the EMS agency medical director determines that the EMS provider has not demonstrated competency in the knowledge and skills to perform the skills within the EMS provider’s scope of practice, or a commitment to adequately perform other functions relevant to the EMS provider providing EMS at that level, and recommending restrictions on the EMS provider’s practice for the EMS agency, if appropriate, to ensure patient safety.

     (ix)   Providing medical direction for the EMS agency dispatch center if the EMS agency operates an EMS agency dispatch center.

   (2)  Maintaining a liaison with the regional EMS medical director.

   (3)  Participating in the regional and Statewide quality improvement programs.

   (4)  Recommending to the relevant regional EMS council, when appropriate, EMS protocols for inclusion in the Statewide and regional EMS protocols.

   (5)  Recommending to the Department the suspension, revocation or restriction of an EMS provider’s certification.

 (b)  Minimum qualifications. To qualify and continue to function as an EMS agency medical director, an individual shall:

   (1)  Be a physician.

   (2)  Satisfy one of the following:

     (i)   Have successfully completed an emergency medicine residency program accredited by a residency program accrediting body recognized by the State Board of Medicine or the State Board of Osteopathic Medicine.

     (ii)   Have successfully completed a residency program in surgery, internal medicine, family medicine, pediatrics or anesthesiology, accredited by a residency program accrediting body recognized by the State Board of Medicine or the State Board of Osteopathic Medicine. The physician shall also have successfully completed or taught the ACLS course within the preceding 2 years and have completed, at least once, the ATLS course and PALS course or APLS course, or other programs determined by the Department to meet or exceed the standards of these programs.

     (iii)   Have served as an ALS medical director under the Emergency Medical Services Act (35 P. S. § §  6921—6938) (repealed by the act of August 18, 2009 (P. L. 308, No. 37)) prior to February 16, 2010.

   (3)  Have a valid Drug Enforcement Agency number.

   (4)  Have completed an EMS agency medical director course or an EMS fellowship or other EMS training program that is determined by the Department to be equivalent. This training shall ensure that the EMS agency medical director has knowledge of:

     (i)   The scope of practice of EMS providers.

     (ii)   The provision of EMS under Statewide EMS protocols.

     (iii)   The interface between EMS providers and medical command physicians.

     (iv)   Quality improvement and peer review principles.

     (v)   Emergency medical dispatch principles and EMS agency communication capabilities.

     (vi)   EMS system design and operation.

     (vii)   Federal and State laws and regulations regarding EMS.

     (viii)   Regional and State mass casualty and disaster plans.

     (ix)   Patient and EMS provider safety principles.

Cross References

   This section cited in 28 Pa. Code §  1023.21 (relating to general rights and responsibilities); 28 Pa. Code §  1027.3 (relating to licensure and general operating standards); and 28 Pa. Code §  1033.2 (relating to administration, management and medical direction requirements).



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