DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and Emergency Medical Services Division RULES PERTAINING TO EMERGENCY MEDICAL SERVICES 6 CCR 1015-3 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] Section 1 – Purpose and Authority for Rules 1.1 These rules address the recognition process for emergency medical services (EMS) education programs; the certification process for all levels of emergency medical technician; the procedures for denial, revocation, suspension, limitation, or modification of an emergency medical technician certificate; the collection of essential data related to the performance and needs of the emergency medical care system in Colorado; and the licensure of ground and air ambulance services. 1.2 The authority for the promulgation of these rules is set forth in Section 25-3.5-101 et seq., C.R.S. Section 2 – Definitions 2.1 All definitions that appear in Section 25-3.5-103, C.R.S., shall apply to these rules. 2.2 "Advanced Cardiac Life Support (ACLS)” – A course of instruction designed to prepare students in the practice of advanced emergency cardiac care.

2.3 "Board of Medical Examiners (BME) Rules" – Rules adopted by the Board of Medical Examiners that establish the responsibilities of medical directors and all authorized acts of emergency medical technicians, located at 3 CCR 713-6, Rule 500.

2.4 "Continuing Education" – Education required for the renewal of a state or national emergency medical technician certificate.

2.5 "Council" – State Emergency Medical and Trauma Services Advisory Council. 2.6 "Department" – Colorado Department of Public Health and Environment. 2.7 "Emergency Medical Technician-Basic (EMT-Basic)" – An individual who has a current and valid EMT-Basic certificate issued by the Department and who is authorized to provide basic emergency medical care in accordance with BME rules.

2.8 “Emergency Medical Technician-Basic with IV Authorization” – An individual who has a current and valid EMT-Basic certificate issued by the Department and who has met the conditions defined in Section 4 of the BME rules relating to IV authorization. 2.9 "Emergency Medical Technician-Intermediate (EMT-Intermediate)" – An individual who has a current and valid EMT-Intermediate certificate issued by the Department and who is authorized to provide limited acts of advanced emergency medical care in accordance with BME rules. 2.10 "Emergency Medical Technician-Paramedic (EMT-Paramedic)" – An individual who has a current and valid EMT-Paramedic certificate issued by the Department and who is authorized to provide limited acts of advanced emergency medical care in accordance with BME rules. 2.11 “EMS Education Center" – A state-recognized provider of initial courses that qualify graduates for state or national emergency medical technician certification or for expanded scope of practice. 2.12 "EMS Education Group" – A state-recognized provider of EMS continuing education topics and/or refresher courses that qualify individuals for renewal of a state or national emergency medical technician certification.

2.13 "EMS Education Program" – A state-recognized provider of EMS education including a recognized education group, center or hospital.

2.14 "EMS Education Program Standards" – Department approved minimum standards for EMS education that shall be met by state-recognized EMS education programs. 2.15 "Emergency Medical Technician Refresher Course" – A course of study based on the Department approved curriculum that meets the education requirements for renewal of a state or national emergency medical technician certificate.

2.16 "Graduate EMT-Intermediate" – An individual who has successfully completed a Department recognized EMT-Intermediate education course but has not yet successfully completed the certification requirements set forth in these rules.

2.17 "Graduate EMT-Paramedic" – An individual who has successfully completed a Department recognized EMT-Paramedic education course but has not yet successfully completed the certification requirements set forth in these rules.

2.18 “Initial Course" – A course of study based on a Department approved curriculum that prepares a person for first-time state or national EMT certification, or for expanded scope of practice as defined by BME rules.

2.19 “Initial EMT Certification” – First time application for and issuance by the Department of a certificate at any EMT level. This shall include applications received from persons holding any level of certification issued by the Department who are applying for either a higher or lower level certificate.

2.20 “Letter of Admonition” – A form of disciplinary sanction that is placed in a certificate holder’s file and represents an adverse action against the certificate holder. 2.21 "Medical Director" – A physician holding an active Colorado medical license who authorizes and directs, through established protocols and standing orders, the performance of students-in- training enrolled in state-recognized EMS education programs, graduate EMT-Intermediates or EMT-Paramedics, or state-certified EMTs who perform medical acts, and who is specifically identified as being responsible to assure the performance competency of those authorized individuals as described in the physician's medical continuous quality improvement program. 2.22 "National Registry of Emergency Medical Technicians (NREMT)" – A national EMT certification organization.

2.23 "Practical Skills Examination" – A skills test conducted at the end of an initial course and prior to application for national or state EMT certification.

2.24 “Provisional Certification” – A certification, valid for not more than 90 days, that may be issued by the Department to an applicant seeking certification as an EMT. Section 3 – State Recognition of Emergency Medical Services (EMS) Education Programs 3.1 Specialized Education Curricula 3.1.1 The specialized education curricula established by the Department include but are not limited to the following:

A) EMT-Basic initial and refresher courses B) EMT-Basic intravenous therapy (IV) course C) EMT-Intermediate initial and refresher courses D) EMT-Paramedic initial and refresher courses E) EMS instructor courses 3.2 Application for State Recognition as an EMS Education Program 3.2.1 The Department may grant recognition for any of the following types of EMS education programs:

A) EMT-Basic education center B) EMT-Basic education group C) EMT-Basic IV education group D) EMT-Intermediate education center E) EMT-Intermediate education group F) EMT-Paramedic education center G) EMT-Paramedic education group 3.2.2 Any education provider seeking to conduct EMS education to prepare graduates for national or state EMT certification shall apply for state recognition as described below. 3.2.3 Initial EMS education program recognition shall be valid for a period of three (3) years from the date of the Department's written notice of recognition. 3.2.4 EMS education programs shall utilize personnel who meet the qualification requirements in state EMS education program standards.

3.2.5 State-recognized EMS education programs are required to present current Colorado emergency medical technician scope of practice content, as established in BME rules, within every emergency medical technician initial and refresher course. 3.2.6 EMS education centers that provide initial education at the EMT-Paramedic level shall obtain accreditation from the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The EMS education center shall provide the Department with verification that an application for accreditation has been submitted to CAAHEP prior to the EMS education center initiating a second course.

3.2.7 EMS education centers that provide initial education at the EMT-Paramedic level shall maintain accreditation from CAAHEP. Loss of CAAHEP accreditation by an EMS education center shall result in proceedings for the revocation, suspension, limitation or modification of state recognition as an EMS education program. 3.2.8 Applicants for state EMS education program recognition shall submit the following documentation to the Department:

A) a completed application form provided by the Department; B) a personnel roster, to include a current resume for the program director and medical director;

C) a description of the facilities to be used for course didactic, lab, and clinical instruction and a listing of all education aids and medical equipment available to the program;

D) program policies and procedures, which at a minimum shall address: 1) admission requirements;

2) attendance requirements;

3) course schedule that lists as separate elements the didactic, lab, clinical, skills and written testing criteria of the education program; 4) discipline/counseling of students;

5) grievance procedures;

6) successful course completion requirements;

7) testing policies;

8) tuition policy statement;

9) infection control plan;

10) description of insurance coverage for students, both personal liability and worker's compensation;

11) practical skills testing policies and procedures and 12) a continuous quality improvement plan.

3.2.9 After receipt of the application and other documentation required by these rules, the Department shall notify the applicant of recognition or denial as an EMS education program, or shall specify a site review or modification of the materials submitted by the applicant.

3.2.10 If the Department requires a site visit, the applicant shall introduce staff, faculty, and medical director, and show all documentation, equipment, supplies and facilities. 3.2.11 Applications determined to be incomplete shall be returned to the applicant. 3.2.12 The Department shall provide written notice of EMS education program recognition or denial of recognition to the applicant. The Department's determination shall include, but not be limited to, consideration of the following factors: A) fulfillment of all application requirements;

B) demonstration of ability to conduct EMS education in compliance with the Department's EMS education program standards;

C) demonstration of necessary professional staff, equipment and supplies to provide the education.

3.2.13 Denial of recognition shall be in accordance with Section 4 of these rules. 3.3 EMS Education Program Recognition Renewal 3.3.1 Renewal of recognition shall be valid for a period of five (5) years from the date of the Department's notice of recognition renewal and shall be based upon satisfactory past performance and submission of an updated application form. 3.3.2 Additional information as specified in Section 3.2.8 may be required by the Department. The Department may require a site review in conjunction with the renewal application. Section 4 – Disciplinary Sanctions and Appeal Procedures for EMS Education Program Recognition 4.1 The Department, in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S., may initiate proceedings to deny, revoke, suspend, limit or modify EMS education program recognition for, but not limited to, the following reasons: 4.1.1 the applicant fails to meet the application requirements specified in Section 3 of these rules.

4.1.2 the applicant does not possess the necessary qualifications to conduct an EMS education program in compliance with EMS education program standards. 4.1.3 the applicant fails to demonstrate access to adequate clinical or internship services as required in EMS education program standards.

4.1.4 fraud, misrepresentation, or deception in applying for or securing EMS education program recognition.

4.1.5 failure to conduct the EMS education program in compliance with EMS education program standards.

4.1.6 failure to notify the Department of changes in the program director or medical director. 4.1.7 providing false information to the Department with regard to successful completion of education or practical skill examination.

4.1.8 failure to comply with the provisions in Section 3 of these rules. 4.2 If the Department initiates proceedings to deny, revoke, suspend, limit or modify an EMS education program recognition, the Department shall provide notice of the action to the EMS education program (or program applicant) and shall inform the program (or program applicant) of its right to appeal and the procedure for appealing. Appeals of Departmental actions shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S. Section 5 – Emergency Medical Technician Certification 5.1 General Requirements 5.1.1 The Department may issue the following EMT certifications: A) EMT-Basic B) EMT-Intermediate C) EMT-Paramedic D) Provisional 90-day EMT certification at the Basic, Intermediate or Paramedic level. 5.1.2 No person shall hold himself or herself out as an EMT or offer, whether or not for compensation, any services included in these rules or authorized acts permitted by the Board of Medical Examiners rules (BME rules), unless that person is currently state- certified as an EMT under these regulations, or is working under the provisions of the BME rules pertaining to Graduate EMT-Intermediate or Graduate EMT-Paramedic, or otherwise authorized by law.

5.1.3 Certificates shall be effective for a period of three (3) years after the date of issuance. The date of issuance shall be determined by the date the Department approves the application.

5.1.4 Upon the expiration date of a Department-issued EMT certificate, the person named in the certificate is no longer a currently certified EMT and is not authorized to act as a state- certified EMT, except under the circumstances specified below in Section 5.1.5. 5.1.5 Pursuant to Section 24-4-104(7), C.R.S., of the State Administrative Procedure Act, if an EMT has made timely and sufficient application for certification renewal and the Department fails to take action on the application prior to the certificate’s expiration date, the EMT’s existing certification shall not expire until the Department acts upon the application. The Department, in its sole discretion, shall determine whether the application was timely and sufficient.

5.1.6 Multiple certifications within the levels of EMT shall not be permitted. Certification at a higher level indicates that the holder of the certificate may also provide medical care allowed under a lower level of certification, provided the lower level certification has not been revoked, modified, suspended, or expired.

5.1.7 If a currently certified EMT seeks a higher or lower level of certification, he or she shall satisfy the requirements for initial certification at the new EMT level, except as described below.

A) If the higher level EMT certification is valid and in good standing, the applicant for a lower level certificate shall not be required to submit current and valid certification from the NREMT at the lower EMT level.

5.2 Initial EMT Certification 5.2.1 Applicants for initial EMT certification shall:

A) be no less than 18 years of age at the time of application; B) submit to the Department a completed application form provided by the Department, and C) submit to the Department with a completed application form all of the following: 1) evidence of current and valid certification from the NREMT at or above the EMT level being applied for.

2) evidence of compliance with criminal history record check requirements: a. The applicant is not required to submit to a fingerprint-based criminal history record check if the applicant has lived in Colorado for more than three (3) years at the time of application and the applicant has submitted to a fingerprint-based criminal history record check through the Colorado Bureau of Investigations (CBI) for a previous Colorado EMT certification application. b. If the applicant has lived in Colorado for more than three (3) years at the time of application and has not submitted to a fingerprint- based criminal history record check as described in subparagraph a above, the applicant shall submit to a fingerprint- based criminal history record check generated by the CBI. c. If the applicant has lived in Colorado for three (3) years or less at the time of application, the applicant shall submit to a fingerprint- based criminal history record check generated by the Federal Bureau of Investigations (FBI) through the CBI.

d. If, in accordance with subparagraphs b or c above, an applicant has twice submitted to a fingerprint-based criminal history record check and the FBI or CBI has been unable to classify the fingerprints, then the Department may accept a CBI and/or FBI name-based criminal history report generated through the CBI. 3) evidence of current and valid professional level basic Cardiac Life Support (CPR) course completion from a national or local organization approved by the Department.

4) In addition to paragraph 3 above, EMT-Intermediate and EMT-Paramedic applicants shall submit evidence of current and valid Advanced Cardiac Life Support (ACLS) course completion from a national or local organization approved by the Department.

5) evidence of lawful presence in the United States.

5.3 Renewal of EMT Certification 5.3.1 General Requirements A) Any person who holds an expired EMT certificate is not a state-certified EMT and shall not hold himself or herself out as such or provide medical care in the capacity of a state-certified EMT.

B) Persons who have permitted their certification to expire for a period not to exceed six (6) months from the expiration date may renew their certification by complying with the provisions of Section 5.3 of these rules (Renewal of EMT Certification). C) Persons who have permitted their certification to expire for a period of greater than six (6) months from the expiration date shall not be eligible for renewal and shall comply with the provisions of Section 5.2 of these rules (Initial EMT Certification). D) All certificates renewed by the Department shall be valid for three (3) years from the date of issuance.

E ) Date of issuance is the date of application approval by the Department, except, for applicants successfully completing the renewal of certification requirements during the last six (6) months prior to their certificate expiration date, the date of issuance shall be the expiration date of the current valid certificate being renewed.

F) Pursuant to Section 24-4-104(7), C.R.S., of the State Administrative Procedure Act, if an EMT has made timely and sufficient application for certification renewal and the Department fails to take action on the application prior to the certificate’s expiration date, the EMT’s existing certification shall not expire until the Department acts upon the application. The Department, in its sole discretion, shall determine whether the application was timely and sufficient. 5.3.2 Application for Renewal of EMT Certification An applicant for renewal of an EMT certification shall: A) submit to the Department a completed application form provided by the Department; B) submit to the Department with a completed application form all of the following: 1) evidence of compliance with criminal history record check requirements: a. The applicant is not required to submit to a fingerprint-based criminal history record check if the applicant has lived in Colorado for more than three (3) years at the time of application and the applicant has submitted to a fingerprint-based criminal history record check through the Colorado Bureau of Investigations (CBI) for a previous Colorado EMT certification application. b. If the applicant has lived in Colorado for more than three (3) years at the time of application and has not submitted to a fingerprint- based criminal history record check as described in subparagraph a above, the applicant shall submit to a fingerprint- based criminal history record check generated by the CBI. c. If the applicant has lived in Colorado for three (3) years or less at the time of application, the applicant shall submit to a fingerprint- based criminal history record check generated by the Federal Bureau of Investigations (FBI) through the CBI.

d. If, in accordance with subparagraphs b or c above, an applicant has twice submitted to a fingerprint-based criminal history record check and the FBI or CBI has been unable to classify the fingerprints, then the Department may accept a CBI and/or FBI name-based criminal history report generated through the CBI. 2) evidence of current and valid professional level Basic Cardiac Life Support (CPR) course completion from a national or local organization approved by the Department.

3) In addition to paragraph 2 above, EMT-Intermediate and EMT-Paramedic applicants shall submit evidence of current and valid Advanced Cardiac Life Support (ACLS) course completion from a national or local organization approved by the Department.

4) evidence of lawful presence in the United States.

C) complete one of the following:

1) current and valid certification with the NREMT at or above the EMT level being renewed.

2) appropriate level refresher course conducted or approved through signature of a Department-recognized EMS education program representative. 3) the minimum number of education hours completed or approved through signature of a Department-recognized EMS education program representative.

4) skill competency as attested to by signature of Medical Director or Department-recognized EMS education program representative. 5.3.3 Education Requirements to Renew an EMT Certificate Without the Use of a Current and Valid NREMT Certification A) For renewal of a Department-issued EMT certificate without the use of a current and valid NREMT certification, the following education is required: 1) Education required for the renewal of an EMT-Basic certificate shall be no less than thirty-six (36) hours and shall be completed through one of the following:

a. a refresher course at the EMT-Basic level conducted or approved by a Department-recognized EMS education program plus additional continuing education topics such that the total education hours is no less than thirty-six (36) hours.

b. continuing education topics consisting of no less than thirty-six (36) hours of education that is conducted or approved through a Department-recognized EMS education program consisting of the following minimum content requirements on the EMT-Basic level:

i) one (1) hour of preparatory content that may include scene safety, quality improvement, health and safety of the EMT, or medical legal concepts.

ii) three (3) hours of OB and pediatric patient assessment and treatment.

iii) six (6) hours of trauma patient assessment and treatment. iv) five (5) hours of patient assessment.

v) three (3) hours of airway assessment and management. vi) six (6) hours of medical/behavioral emergency patient assessment and management.

vii) twelve (12) hours of elective content that is relevant to the practice of emergency medicine.

2) Education required for the renewal of an EMT-Intermediate or EMT- Paramedic certificate shall be no less than fifty (50) hours and shall be completed through one of the following methods:

a. a refresher course at the EMT's level conducted or approved by a Department-recognized EMS education program plus additional continuing education topics such that the total education hours is no less than fifty (50) hours.

b. continuing education topics consisting of no less than fifty (50) hours of education that is conducted or approved through a Department-recognized EMS education program consisting of the following minimum content requirements at the EMT’s level: No less than twenty-five (25) hours as described below: i) eight (8) hours of airway, breathing, and cardiology assessment and treatment.

ii) four (4) hours of medical patient assessment and treatment. iii) three (3) hours of trauma patient assessment and treatment. iv) eight (8) hours of OB and pediatric patient assessment and treatment.

v) two (2) hours of operational tasks and no less than twenty- five (25) hours of elective content that is relevant to the practice of emergency medicine.

5.4 Provisional EMT Certification 5.4.1 General Requirements A) The Department may issue a provisional EMT certification to an applicant whose fingerprint-based criminal history record check has not been received by the Department at the time of application for certification. B) To be eligible for a provisional certification, the applicant shall, at the time of application, have satisfied all requirements in these rules for initial or renewal certification.

C) A provisional certification shall be valid for not more than ninety days. D) The Department may renew a provisional certification. E) The Department may impose disciplinary sanctions pursuant to these rules if the Department finds that an EMT who has received a provisional certification has violated any of the certification requirements or any of these rules. F) Once a provisional certification becomes invalid, an applicant may not practice or act as an EMT unless an initial or renewal certification has been issued by the Department to the applicant.

5.4.2 Application for Provisional Certification An applicant for a provisional certification shall:

A) submit to the Department a completed application form provided by the Department. 1) The applicant shall request a provisional certification. B) submit to a fingerprint-based criminal history record check as provided in sections 5.2.1 and 5.3.2 of these rules. At the time of application, the applicant shall have already submitted the required materials to the CBI to initiate the fingerprint- based criminal history record check.

C) submit to the Department with a completed application form all of the following: 1) a fee in the amount of $ 23.00.

2) a name-based criminal history record check.

a. If the applicant has lived in Colorado for more than three (3) years at the time of application, a name-based criminal history report conducted by the CBI, including any internet-based system on CBI’s website, or other name-based report as determined by the Department.

b. If the applicant has lived in Colorado for three (3) years or less at the time of application, a name-based criminal history report for each state in which the applicant has lived for the past three (3) years, conducted by the respective states’ bureaus of investigation or equivalent state-level law enforcement agency, or other name- based report as determined by the Department.

c. Any name-based criminal history report provided to the Department for purposes of this paragraph c shall have been obtained by the applicant not more than 90 days prior to the Department’s receipt of a completed application.

Section 6 – Disciplinary Sanctions and Appeal Procedures for EMT Certification 6.1 For good cause, the Department may deny, revoke, suspend, limit, modify, or refuse to renew an EMT certificate, may impose probation on a certificate holder, or may issue a letter of admonition in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S. 6.2 Good cause for disciplinary sanctions listed above shall include, but not be limited to: 6.2.1 failure to meet the requirements of these rules pertaining to issuance and renewal of EMT certification.

6.2.2 fraud, misrepresentation, or deception in applying for or securing EMT certification. 6.2.3 aiding and abetting in the procurement of EMT certification for any person not eligible for certification.

6.2.4 utilizing NREMT certification that has been illegally obtained, suspended or revoked, to obtain a state EMT certification.

6.2.5 unlawful use, possessing, dispensing, administering, or distributing controlled substances. 6.2.6 driving an emergency vehicle in a reckless manner, or while under the influence of alcohol or other performance altering substances.

6.2.7 responding to or providing patient care while under the influence of alcohol or other performance altering substances.

6.2.8 demonstrating a pattern of alcohol or other substance abuse. 6.2.9 materially altering any Department EMT certificate, or using and/or possessing any such altered EMT certificate.

6.2.10 having an EMT certificate or license suspended or revoked in another state or country. 6.2.11 unlawfully discriminating in the provision of services. 6.2.12 representing qualifications at any level other than the person's current EMT certification level.

6.2.13 representing oneself to others as an EMT or providing medical care without possessing a current and valid EMT certificate issued by the Department. 6.2.14 failing to follow accepted standards of care in the management of a patient, or in response to a medical emergency.

6.2.15 failing to administer medications or treatment in a responsible manner in accordance with the medical director's orders or protocols.

6.2.16 failing to maintain confidentiality of patient information. 6.2.17 failing to provide the Department with the current place of residence or failing to promptly notify the Department of a change in current place of residence or change of name. 6.2.18 a pattern of behavior that demonstrates routine response to medical emergencies without being under the policies and procedures of a designated emergency medical response agency and/or providing patient care without medical direction when required. 6.2.19 performing medical acts not authorized by the BME rules and in the absence of any other lawful authorization to perform such medical acts.

6.2.20 failing to provide care or discontinuing care when a duty to provide care has been established.

6.2.21 appropriating or possessing without authorization medications, supplies, equipment, or personal items of a patient or employer.

6.2.22 falsifying entries or failing to make essential entries in a patient care report, EMS education document, or medical record.

6.2.23 falsifying or failing to comply with any collection or reporting required by the state. 6.2.24 failing to comply with the terms of any agreement or stipulation regarding EMT certification entered into with the Department.

6.2.25 violating any state or federal statute or regulation, the violation of which would jeopardize the health or safety of a patient or the public.

6.2.26 unprofessional conduct at the scene of an emergency that hinders, delays, eliminates, or deters the provision of medical care to the patient or endangers the safety of the public. 6.2.27 failure by a certificate holder to report to the Department any violation by another EMT of the good cause provisions of this section when the certificate holder knows or reasonably believes a violation has occurred.

6.2.28 committing or permitting, aiding or abetting the commission of an unlawful act that substantially relates to performance of an EMT’s duties and responsibilities as determined by the Department.

6.3 Good cause for disciplinary sanctions also includes conviction of, or a plea of guilty, or of no contest, to a felony or misdemeanor that relates to the duties and responsibilities of an EMT, including patient care and public safety. For purposes of this paragraph, “conviction” includes the imposition of a deferred sentence.

6.3.1 The following crimes set forth in the Colorado Criminal Code (Title 18, C.R.S.) are considered to relate to the duties and responsibilities of an EMT: A) offenses under Article 3 – offenses against a person. B) offenses under Article 4 – offenses against property. C) offenses under Article 5 – offenses involving fraud. D) offenses under Article 6 – offenses involving the family relations. E) offenses under Article 6.5 – wrongs to at-risk adults. F) offenses under Article 7 – offenses related to morals. G) offenses under Article 8 – offenses – governmental operations. H) offenses under Article 9 – offenses against public peace, order and decency. I) offenses under Article 17 – Colorado Organized Crime Control Act. J) offenses under Article 18 – Uniform Controlled Substances Act of 1992. 6.3.2 The offenses listed above are not exclusive. The Department may consider other pleas or criminal convictions, including those from other state, federal, foreign or military jurisdictions.

6.3.3 In determining whether to impose disciplinary sanctions based on a plea or on a felony or misdemeanor conviction, the Department may consider, but is not limited to, the following information:

A) the nature and seriousness of the crime including but not limited to whether the crime involved violence to or abuse of another person and whether the crime involved a minor or a person of diminished capacity;

B) the relationship of the crime to the purposes of requiring a certificate; C) the relationship of the crime to the ability, capacity or fitness required to perform the duties and discharge the responsibilities of an EMT; and D) the time frame in which the crime was committed.

6.4 Appeals 6.4.1 If the Department denies EMT certification, the Department shall provide the applicant with notice of the grounds for denial and shall inform the applicant of the applicant’s right to request a hearing.

A) A request for a hearing shall be submitted to the Department in writing within sixty (60) calendar days from the date of the notice.

B) If a hearing is requested, the applicant shall file an answer within sixty (60) calendar days from the date of the notice.

C) If a request for a hearing is made, the hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101 et seq., C.R.S. D) If the applicant does not request a hearing in writing within sixty (60) calendar days from the date of the notice, the applicant is deemed to have waived the opportunity for a hearing.

6.4.2 If the Department proposes disciplinary sanctions as provided in this section, the Department shall notify the certificate holder by first class mail to the last address furnished to the Department by the certificate holder. The notice shall state the alleged facts and/or conduct warranting the proposed action and state that the certificate holder may request a hearing.

A) The certificate holder shall file a written answer within thirty (30) calendar days of the date of mailing of the notice.

B) A request for a hearing shall be submitted to the Department in writing within thirty (30) calendar days from the date of mailing of the notice. C) If a request for a hearing is made, the hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101 et seq., C.R.S. D) If the certificate holder does not request a hearing in writing within thirty (30) calendar days of the date of mailing of the notice, the certificate holder is deemed to have waived the opportunity for a hearing.

6.4.3 If the Department summarily suspends a certificate, the Department shall provide the certificate holder notice of such in writing, which shall be sent by first class mail to the last address furnished to the Department by the certificate holder. The notice shall state that the certificate holder is entitled to a prompt hearing on the matter. The hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.

Section 7 – Placeholder Section 8 – Placeholder Section 9 – Placeholder Section 10 – Placeholder Section 11 - Data and Information Collection and Record Keeping 11.1 Authority The authority and requirement for data collection is provided in C.R.S. § 25-3.5-501(1), which states, “Each ambulance service shall prepare and transmit copies of uniform and standardized records, as specified by regulation adopted by the department, concerning the transportation and treatment of patients in order to evaluate the performance of the emergency medical services system and to plan systematically for improvements in said system at all levels.” Additional authority for data collection and analysis is provided in C.R.S. § 25-3.5-307, requiring data collection and reporting by air ambulance agencies, and C.R.S. § 25-3.5-704(2)(h), requiring the establishment of a continuous quality improvement system to evaluate the statewide emergency medical and trauma services system.

11.2 Purpose and Scope This section consists of rules for the collection and reporting of essential data related to the performance, needs and quality assessment of the statewide emergency medical and trauma services system. These rules focus primarily on the data that ambulance agencies are required to collect and provide to the Department. Rules regarding the collection of data by designated trauma facilities can be found in 6 CCR 1015-4, Chapter 1. 11.3 Definitions 1. Agency or agencies as used in this section 11 means (ground) ambulance services and air ambulance services.

2. Air Ambulance means a fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.

3. Air Ambulance Service means any governmental or private organization licensed by the department to transport in any aircraft patient(s) who require in-flight medical supervision to a medical facility.

4. Ambulance means any privately or publicly owned ground vehicle that meets the requirements of C.R.S. § 25-3.5-103(1.5).

5. Ambulance service means the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in or professing to be engaged in the transportation of patients by ambulance. Taken in context, it also means the person so engaged or professing to be so engaged. The person so engaged and the vehicles used for the emergency transportation of persons injured at a mine are excluded from this definition when the personnel utilized in the operation of said vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency. 6. Patient means any individual who is sick, injured, or otherwise incapacitated or helpless. 11.4 Reporting Requirements 1. All ambulance service agencies and air ambulance service agencies licensed in Colorado shall provide the Department with the required data and information as specified in sections 2 and 3 below in a format determined by the Department or in an alternate media acceptable to the Department.

2. The required data and information for the agency profile shall be based on the Colorado Emergency Medical Services Information System (CEMSIS). a. Agency profile data shall include but not be limited to information about licensing, service types and level, agency contact information, agency director and medical director contact information, demographics of the service area, number and types of responding personnel, number of calls by response type, data collection methods, counties served, organizational type, and number and type of vehicles. b. Agencies shall provide agency profile data to the Department using the CEMSIS portal website.

c. Agencies shall update agency profile data whenever changes occur and at least annually.

3. The required data and information on patient care shall be based on the National Emergency Medical Services Information System (NEMSIS).

a. These rules incorporate by reference the National Highway Traffic Safety Administration (NHTSA) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 2.2.1, National Elements Subset, published in 2006. Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Department maintains copies of the complete text of required data elements for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the Division by contacting:

EMTS Section Chief Health Facilities and EMS Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 These materials have been submitted to the state publications depository and distribution center and are available for interlibrary loan. The incorporated material may be examined at any state publications depository library. Submission of the National Elements Subset as stated above is required, however, ambulance services may provide additional data as outlined in the complete NEMSIS NHTSA Version 2.2.1 Data Dictionary or as suggested by the Department.

b. All agencies licensed in Colorado shall report the required data elements on all responses that resulted in patient contact. Although not required, agencies may also report the required data elements on responses that did not result in patient contact or transport (all calls).

c. Agencies shall obtain approval from the Department prior to using third party media to submit the required data.

d. Agencies shall provide the data to the Department at least quarterly based on a calendar year or on a schedule submitted to and approved by the Department. The quarterly download must be submitted to the Department within 60 days of the end of the quarter (i.e., data for EMS responses occurring in January through March must be submitted by June 1; for responses in April through June by September 1; for responses in July through September by December 1; for responses in October through December by March 1). The data may be submitted more frequently than quarterly.

4. In order to be eligible to apply for funding through the EMTS grants program, agencies shall provide agency profile information as described in section 2 and regularly submit patient care information as described in section 3.

5. If an agency fails to comply with these rules, the Department may report this lack of compliance to the county(ies) in which the agency is licensed and/or to the agency’s medical director.

11.5 Confidentiality of Data and Information on Patient Care 1. The data and information provided to the Department in accordance with 11.4 section 3 of these rules shall be used to conduct continuing quality improvement of the Emergency Medical and Trauma System, pursuant to C.R.S. § 25-3.5-704 (2)(h)(I). Any data provided to the department that identifies an individual patient’s, provider’s or facility’s care outcomes or is part of the patient’s medical record shall be strictly confidential, whether such data are recorded on paper or electronically. The confidentiality protections provided in C.R.S. § 25-3.5-704 (2)(h)(II) apply to this data. 2. Any patient care data in the EMS data system that could potentially identify individual patients or providers shall not be released in any form to any agency, institution, or individual, except as provided in section 11.5,3.

3. An agency may retrieve the patient care data that the agency has submitted via the Department’s web-based data entry utility and that are stored on the Department’s servers.

4. Results from any analysis of the data by the Department shall only be presented in aggregate according to established Department policies.

5. The Department may establish procedures to allow access by outside agencies, institutions or individuals to information in the EMS data system that does not identify patients, providers or agencies. These procedures are outlined in the Colorado EMS Data System Data Release Policy and other applicable Department data release policies. Section 12 - Licensure Of Ambulance Services 12.1 Purpose And Scope 12.1.1 These rules are promulgated pursuant to § 25-3.5-308, CRS (2004). They are consistent with § 25-3.5-301, 302, and 304 -306, CRS (2004). Each county may adopt rules that exceed these rules adopted herein.

12.2 Definitions 12.2.1 Based: an ambulance service headquartered, having a substation, office ambulance post or other permanent location in a county.

12.2.2 County: county or city and county government within Colorado. 12.2.3 Department: the Colorado Department of Public Health and Environment. 12.2.4 Ambulance: any public or privately owned land vehicle especially constructed or modified and equipped, intended to be used and maintained or operated by, ambulance services for the transportation, upon the roads, streets and highways of this state, of individuals who are sick, injured, or otherwise incapacitated or helpless. 12.2.5 Ambulance-advanced life support: a type of permit issued by a county to a vehicle equipped in accordance with Section 9 of these rules and operated by an ambulance service authorizing the vehicle to be used to provide ambulance service limited to the scope of practice of the emergency medical technician-intermediate or emergency medical technician-paramedic as defined in the Colorado Board of Medical Examiners rules, 3 CCR 713-6, Rule 500, Sections 5 and 6.

12.2.6 Ambulance-basic life support: a type of permit issued by a county to a vehicle equipped in accordance with Section 9 of these rules and authorized to be used to provide ambulance service limited to the scope of practice of the emergency medical technician- basic as defined in the Colorado Board of Medical Examiners rules, 3 CCR 713-6, rule 500, section 4.

12.2.7 Ambulance service license: a legal document issued to an ambulance service by a county as evidence that the applicant meets the requirements for licensure to operate an ambulance service as defined by county resolution or regulations. 12.2.8 Ambulance service: the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in or professing to be engaged in the transportation of patients by ambulance. Taken in context, the person so engaged or professing to be so engaged and the vehicles used for the emergency transportation of persons injured at a mine are excluded from this definition when the personnel utilized in the operation of said vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency.

12.2.9 Medical Director: a Colorado licensed physician who establishes protocols and standing orders for medical acts performed by department-certified EMTs of a prehospital EMS service agency and who is specifically identified as being responsible to assure the competency of the performance of those acts by such department-certified EMTs as described in the physician’s medical continuous quality improvement program. Any reference to a “physician advisor” in the state EMS rules or in the Board of Medical Examiners previously adopted rules shall apply to a “medical director” as defined in these rules.

12.2.10 Patient Care Report: a medical record of an encounter between any patient and a provider of medical care.

12.2.11 Permit: the authorization issued by the governing body of a local government with respect to an ambulance used or to be used to provide ambulance service in this state. 12.2.12 Medical quality improvement program: a process consistent with Colorado Board of Medical Examiners rules, 3 CCR 713-6, Rule 500, Section 3.2 (b), used to objectively, systematically and continuously monitor, assess and improve the quality and appropriateness of care provided by the medical care providers operating on an ambulance service.

12.2.13 Rescue Unit: any organized group chartered by this state as a corporation not for profit or otherwise existing as a nonprofit organization whose purpose is the search for and the rescue of lost or injured persons and includes, but is not limited to, such groups as search and rescue, mountain rescue, ski patrols, (either volunteer or professional), law enforcement posses, civil defense units, or other organizations of governmental designation responsible for search and rescue.

12.2.14 Quick Response Teams: provides initial care to a patient prior to the arrival of an ambulance.

12.3 County Issuance Of Licenses And Permit 12.3.1 License Required A) Within one year following adoption of these rules, no person or agency, private or public, shall transport a patient from any point within Colorado in an ambulance, to any point within or outside Colorado unless that person or agency holds a valid license and permits issued by the county where the service is based and by the county where the patient originates, except as provided in subsection 3.2 of these rules.

B) Ambulance services that are based outside Colorado, but respond within Colorado and transport patients originating in Colorado are required to be licensed in Colorado by the county in which they provide service.

C) Counties may enter into reciprocal licensing and permitting agreements with other counties and neighboring states.

12.3.2 County Exemptions From Licensure or Permit Requirements A) Vehicles used for the transportation of persons injured at a mine when the personnel used on the vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency. B) Vehicles used by other agencies including quick response teams and rescue units that do not routinely transport patients or vehicles used to transport patients for extrication from areas inaccessible to a permitted ambulance. Vehicles used in this capacity may only transport patients to the closest practical point for access to a permitted ambulance or hospital.

C) Vehicles, including ambulances from another state, used during major catastrophe or mass casualty incident rendering services when permitted ambulances are insufficient.

D) An ambulance service that does not transport patients from points originating in Colorado, or transporting a patient originating outside the borders of Colorado. E) Vehicles used or designed for the scheduled transportation of convalescent patients, individuals with disabilities, or persons who would not be expected to require skilled treatment or care while in the vehicle.

F) Vehicles used solely for the transportation of intoxicated persons or persons incapacitated by alcohol as defined in § 25-1-302, CRS (2004) but who are not otherwise disabled or seriously injured and who would not be expected to require skilled treatment or care while in the vehicle.

G) Ambulances operated by a department or an agency of the federal government, originating from a federal reservation for the purpose of responding to, or transporting patients under federal responsibility.

12.3.3 General Requirements For County Licensure Of Ambulance Services A) Counties shall adopt by resolution or regulations a process for licensure of ambulance services. The process shall include, but not be limited to: 1) Compliance with applicable federal, state, and local laws and regulations to operate an ambulance service in Colorado.

2) An application form adopted by the county.

3) An application fee, as defined in county resolution or regulations. 4) Submission to the county, upon request, of copies of the ambulance service’s written policy and procedure manual, operational or medical protocols, or other documentation the county may deem necessary.

5) Demonstration by the applicant of minimum vehicle insurance coverage as defined by § 10-4-609, CRS and § 42-7-103 (2), CRS (2004) with the county(s) identified as the certificate holder.

6) Demonstration by the applicant of proof of any additional insurance as identified in county resolution or regulations. In making a decision about additional insurance requirements at any time it deems necessary to promote the public health, safety and welfare, the county shall require a minimum level of worker’s compensation consistent with the Colorado worker’s compensation act of Colorado title 8, article 4 0-47. 7) Documentation from the applicant that information regarding the amount of professional liability insurance the ambulance service carries was provided to employees.

8) Prior to beginning operations and upon change of ownership of an ambulance service, the new owner or operator must file for and obtain an ambulance license and ambulance permit.

9) The county may adopt minimum acceptable vehicle design standards for ambulances. In doing so, the county shall consider vehicle design standards such as those established by the US General Services Administration: federal specifications for ambulances KKK-A-1822 (e), 2003.

10) The county shall verify that each ambulance is inspected annually by qualified representatives, as defined and appointed by the county commissioners, to assure compliance with these rules.

11) Counties shall verify that all equipment on the ambulance is properly secured, and medications and supplies are maintained and stored according to the manufacturer’s recommendations and any federal, state or local requirements.

12) A county may delegate or contract the ambulance inspection process but not the responsibility of licensure as defined by Colorado statute and the rules as defined in § 25-3.5-301, CRS (2004)

13) An ambulance service license or vehicle permit may not be assigned, sold or otherwise transferred.

B) These rules incorporate by reference (Section 12.3.3 (a) (9)) materials originally published elsewhere. These rules do not include later amendments to or editions of the incorporated materials. The Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. The incorporated material may be examined at any state publications depository library.

Information regarding how the incorporated materials may be obtained or examined is available from:

Emergency Medical and Trauma Services Section Chief, Health Facilities and Emergency Medical Services Division, Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Denver, Colorado 80246 12.3.4 Licensure Process A) Ambulance Service License 1) An ambulance service license shall be issued by county upon compliance with these rules and all license requirements duly established by that county. The type of license issued shall describe the maximum level of ambulance service that could be provided at any time by the service. B) Permits Of Vehicles 1) The county shall create a process and procedure for the issuing of permits for each vehicle used by the ambulance service.

2) The type of permit issued will describe the maximum level of service that could be provided at any time by that vehicle and appropriate staff. Types of permissible permits are limited to:

a. Ambulance basic life support b. Ambulance advanced life support c. Each county shall include in their resolution or regulations the requirements for identification of the permitted level of service on each vehicle issued a permit.

12.3.5 Licensure Period A) The licensure period for all ambulance services shall be for twelve months. 12.3.6 License Renewal A) Counties shall create an annual license renewal process. The license renewal process shall require the ambulance service to submit a completed renewal application form and the required licensure fee, as defined in county resolution or regulations. The licensure renewal process shall require the receipt of applications for renewal no less than 30 days before the date of license expiration.

12.4 Complaints 12.4.1 Each county must have a written complaint and investigation policy and procedure to address:

A) complaints against any ambulance service licensed in the county. B) allegations of unlicensed ambulance services or vehicles without a valid permit operating within the county.

12.4.2 The policy shall include, but not be limited to, the procedures associated with complaint intake; complaint validation; criteria for initiating an investigation; a method for notification to the complainant about the resolution of the investigation; and a method for the notification of other local entities with jurisdiction over ambulance services, the department and/or the Board of Medical Examiners for complaints regarding certified emergency medical technicians, other medical personnel associated with the service or the medical director.

12.4.3 The county shall notify the primary medical director of the ambulance service, in writing, of any violation of the ambulance licensing regulations by the ambulance service or alleged complaints or violations by individual medical providers operating on an ambulance service.

12.5 Denial, Revocation, Or Suspension Of Licensure And Vehicle Permits 12.5.1 Each county shall develop policies and procedures for the denial, suspension or revocation of an ambulance service license or ambulance permit consistent with § 25- 3.5-304, CRS (2004).

12.6 Minimum Data Collection And Reporting Requirements 12.6.1 The county shall require that licensed ambulance services complete a patient care report for each patient that is assessed. The patient care report shall include the minimum pre-hospital care data set as set forth in the Emergency Medical Services Rules, 6 CCR 1015-3.

12.6.2 The county shall require that the ambulance service provide patient care information to the department pursuant to Emergency Medical Services Rules, 6 CCR 1015-3. 12.6.3 The county shall require that each licensed ambulance service complete and submit to the department an agency profile as defined by State Emergency Medical and Trauma Services Advisory Council and approved by the department to provide information on resources available for planning and coordination of statewide emergency medical and trauma services on an annual basis.

12.7 Minimum Staffing Requirements 12.7.1 The county shall establish by resolution or regulations ambulance staffing requirements to include, but not be limited to:

A) The minimum requirement for the person responsible for providing direct emergency medical care to patients transported in an ambulance shall be certified as an emergency medical technician-basic as defined in Emergency Medical Services Rules, 6 CCR 1015-3.

B) The minimum requirement for the ambulance driver shall be a valid driver’s license. 12.7.2 Consistent with § 25-3.5-202, CRS (2004) in the case of an emergency in any ambulance service area where no person possessing the qualifications required by this section is present or available to respond to a call for the emergency treatment and transportation of patients by ambulance, any person may operate such ambulance to transport any sick, injured, or otherwise incapacitated or helpless person in order to stabilize the medical condition of such person pending the availability of personnel meeting these minimum qualifications.

12.8 Medical Oversight And Quality Improvement 12.8.1 The county shall require each ambulance service operating within their jurisdiction to have a primary medical director meeting the requirements established by the Colorado Board of Medical Examiners as defined in the Colorado Board of Medical Examiners 3 CCR 713-6, Rule 500 to supervise the medical acts performed by all personnel on the ambulance service. The county shall require a licensee to inform the county within 15 calendar days, in writing, of changes in medical oversight of the ambulance service and/or the medical director of record.

12.8.2 The county ambulance service licensure application shall include an attestation by the medical director of willingness to provide medical oversight and a medical continuous quality improvement program for the ambulance service.

12.8.3 The county shall require each licensed ambulance service operating within their jurisdiction to have an ongoing medical continuous quality improvement program consistent with the requirements as defined in the Colorado Board of Medical Examiners rules 3 CCR 713-6, Rule 500, 3.2, b.

12.9 Minimum Equipment Requirements 12.9.1 Counties shall ensure that permitted ambulances are in compliance with the minimum equipment list for the type of service defined by their permit as defined in 9.3 and 9.4 of these rules.

12.9.2 Minimum Equipment For Basic Life Support Ambulances A) Ventilation And Airway Equipment 1) portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. 2) bulb syringe 3) house oxygen and portable oxygen bottle, each with a variable flow regulator. 4) transparent, non-re breather oxygen masks and nasal cannula in adult sizes, and transparent, non-re breather oxygen masks in pediatric sizes. 5) hand operated, self inflating bag-valve mask resuscitators with oxygen reservoirs and standard 15mm /21mm fittings in the following sizes: a. 500cc bag for infant and neonate b. 750cc bag for children c. 1000cc bag for adult d. Transparent masks for infants, neonate patients, children and adults. 6) nasopharyngeal airways in adult sizes 24 fr. through 32 fr. 7) oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult.

B) Patient Assessment Equipment 1) blood pressure cuffs to include large adult, regular adult, child and infant sizes.

2) stethoscope.

3) penlight.

C) Splinting Equipment 1) lower extremity traction splint.

2) upper and lower extremity splints.

3) long board, scoop™, vacuum mattress or equivalent with appropriate accessories to immobilize the patient from head to heels. 4) short board, K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis.

5) pediatric spine board or adult spine board that can be adapted for pediatric use.

6) adult and pediatric head immobilization equipment.

7) adult and pediatric cervical spine immobilization equipment per medical director protocol.

D) Dressing Materials 1) bandages - various types and sizes per agency needs and medical director protocol.

2) multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and medical director protocol. 3) sterile burn sheets.

4) adhesive tape per ambulance service requirements, needs and medical director protocol.

E) Obstetrical Supplies 1) sterile ob kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves and thermal absorbent blanket. 2) neonate stocking cap or equivalent.

F) Miscellaneous Equipment 1) heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc.

2) two working flashlights.

3) blankets and appropriate heat source for the ambulance patient compartment. G) Ambulance Service Medical Treatment Protocols.

H) Communications Equipment 1) All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications.

2) Two-way communications that will enable the ambulance personnel to communicate with:

a. ambulance service’s dispatch.

b. medical control facility or a physician c. receiving facilities d. mutual aid agencies I) Extrication Equipment 1) Each ambulance should carry extrication equipment appropriate for the level of extrication the ambulance service provides and in accordance with the requirements established by the county in which the ambulance is licensed.

J) Body Substance Isolation (BSI) Equipment Properly Sized To Fit All Personnel 1) non-sterile disposable gloves, to include a minimum 1 box of latex free gloves.

2) protective eyewear.

3) non-sterile surgical masks.

4) safety protection gear for extrication consistent with the ambulance service extrication capabilities.

5) sharps containers for the appropriate disposal and storage of medical waste and biohazards.

6) HEPA masks, which can be of universal size.

K) Safety Equipment 1) a set of three (3) warning reflectors.

2) one (1) ten pound (10 lb.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior.

3) child safety seat or appropriate protective restraints for patients, crew, accompanying family members and other vehicle occupants. 4) properly secured patient transport system (i.e. wheeled stretcher). 5) triage tags as approved by the department.

12.9.3 Minimum Equipment Requirement for Advanced Life Support Ambulances A) All Equipment Listed In 9.2 B) Ventilation Equipment 1) adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed range from 2/5 – 5/5, and cuffed size range from 6.0-8.0 per medical director protocol.

2) laryngoscope and blades, straight and/or curved of sizes 0-4. 3) adult and pediatric magill forceps.

4) end tidal co 2 detector or alternative device, approved by the FDA, for determining end tube placement.

C) Patient Assessment Equipment 1) portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities.

2) pulse oximeter with adult and pediatric probes.

3) electronic blood glucose measuring device.

D) Intravenous Equipment 1) adult and pediatric intravenous solutions and administration equipment per medical director protocol.

2) adult and pediatric intravenous arm boards.

E) Pharmacological Agents 1) pharmacological agents and delivery devices per medical director protocol. 2) pediatric “length based” device for sizing drug dosage calculations and sizing equipment.

Section 13 - Air Ambulance Licensing 13.1 Purpose and Scope These rules are promulgated pursuant to Section 25-3.5-307, C.R.S. (2007). 13.2 Definitions 1. Air Ambulance: A fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.

2. Air Ambulance License: A legal document issued by the department as evidence that an air ambulance service meets the requirements for licensing as defined in these rules. 3. Air Ambulance Service: Any governmental or private organization licensed by the department to transport in an aircraft patient(s) who require in-flight medical supervision to a medical facility.

4. Aircraft: A rotor or fixed wing vehicle.

5. Commission on Accreditation of Medical Transport Systems (CAMTS): A national not for profit organization that provides accreditation services for air medical and inter-facility transport services.

6. Department: The Colorado Department of Public Health and Environment. 7. Federal Aviation Regulations (FAR): Regulations promulgated by the Federal Aviation Administration of the U.S. Department of Transportation, governing the operation of all aircraft in the United States.

8. Medical Protocol: Written standards for patient medical assessment and management. 9. Patient Care Report (PCR): A medical record of an encounter between any patient and a provider of medical care.

10. Rescue Unit: Any organized group chartered by this state as a corporation not for profit or otherwise existing as a nonprofit organization whose purpose is the search for and the rescue of lost or injured persons and includes, but is not limited to, such groups as search and rescue, mountain rescue, ski patrols, (either volunteer or professional), law enforcement posses, civil defense units, or other organizations of governmental designation responsible for search and rescue.

13.3 Licensing 1. Licensing Required Upon the effective date of these rules, no person, agency, or entity, private or public, shall transport a sick or injured person by aircraft from any point within Colorado, to any point within or outside Colorado unless that person, agency, or entity holds a valid air ambulance service license to do so that has been issued by the department, except as provided in subsection 13.3,2 and 3 of these rules.

2. Exception from Licensing-Exigent Circumstances Upon request, the department may authorize an air ambulance service to provide a particular transport upon a showing of exigent circumstances. Exigent circumstances include but are not limited to:

A. A humanitarian transport as determined by the department. In determining whether to authorize a humanitarian transport, the department shall consider the following factors:

(1) Whether the transport is provided directly or indirectly by an organization whose mission is primarily dedicated toward non-profit or charitable or community care services;

(2) Other available options for the transport;

(3) Whether the transport will be of no cost to the patient; (4) Whether the transport is subsidized by a person or entity associated with the patient;

(5) The qualifications of the transport personnel;

(6) Information obtained from facilities and/or staff involved in the transport; (7) The air ambulance service’s membership in organizations that support safe medical care;

(8) Air ambulance service insurance coverage as applicable; (9) Authorization under local and federal laws to conduct operations; (10) Licensure in other states or by other governmental agencies; (11) The air ambulance service’s safety record;

(12) Whether or not the air ambulance service has been subject to disciplinary sanctions in other jurisdictions;

(13) The air ambulance service’s prior contacts with the department, if any; and (14) Any other considerations deemed relevant by the department on a case by case basis.

B. A disaster or mass casualty event in Colorado that limits the availability of licensed services;

C. A need for specialized equipment not otherwise readily available through Colorado licensed air ambulance services.

3. Licensing Not Required A. An air ambulance service agency that solely transports patients from points originating outside Colorado is not required to be licensed in Colorado. B. Rescue unit aircraft that are not specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision. 13.4 Out of State Air Ambulance Services Licensing Requirements Air ambulance services that are based outside the state, but pick up patients in Colorado, are required to be licensed in Colorado by the department, except as provided in section 13.3,2 of these rules.

13.5 Application for Licensing 1. At the time of application, applicants must be in compliance with all Federal Aviation Regulations such as proof of insurance, aircraft inspection certificates, Federal Aviation Administration part 135 certificate and Federal Communications Commission part 90. 2. Accreditation by CAMTS. Except as provided in 13.5,3 below, applicants that are currently accredited by CAMTS may receive a license to operate an air ambulance service upon completion of the documentation and fees that are required by the department and proof of such accreditation.

3. The department may issue a conditional license to an applicant that has not yet received CAMTS accreditation upon proof that the applicant is actively working toward CAMTS accreditation. The department may require that such proof be verified by CAMTS. Any applicant that receives a conditional license shall complete its CAMTS accreditation within two years after issuance of the initial conditional license. 4. If the holder of a conditional license fails to complete CAMTS accreditation within two years after the issuance of the initial conditional license, its conditional license shall be revoked and no license of any type shall be issued until it demonstrates successful completion of CAMTS accreditation.

5. At such time as any air ambulance service licensed under section 13.3,1 of these rules receives a "notification of potential withdrawal of accreditation" from CAMTS, or is no longer CAMTS accredited, the service shall immediately notify the department. 13.6 Fees All applicants seeking licensure by the department under these air ambulance service rules shall submit the following non-refundable fees with each initial or renewal licensure application: 1. $860 for each air ambulance service, plus $100 for each aircraft used by the air ambulance service.

2. For applicants who are not CAMTS accredited, the applicant shall pay a fee of $525 to the department in addition to the fee set forth in 13.6,1 above. 13.7 Licensing Process 1. To become licensed and maintain licensed status as an air ambulance service, the service shall:

A. Achieve and maintain CAMTS accreditation.

B. Demonstrate compliance with applicable federal, state, and local laws and regulations to operate a business in Colorado.

C. Submit to the department a completed application form and the required application fee.

D. Demonstrate compliance with these rules.

E. Upon request, submit to the department copies of the service's written policy and procedure manual, operation/medical protocols, and other documentation the department may deem necessary.

2. The department may conduct an inspection of the service and its aircraft to assure compliance with these rules.

3. When change of ownership of an air ambulance service occurs, the new owner or operator must file for and obtain an air ambulance service license from the department prior to beginning operations.

13.8 Licensing Period Any air ambulance service license issued by the department shall be valid for a period not to exceed one year.

13.9 Licensing Renewal 1. To renew an existing air ambulance service license, the licensee shall submit a renewal application and fees, as set by the department, no later than three (3) months prior to the date of license expiration.

2. A renewal inspection may be required by the department to assure service compliance with these rules.

13.10 Types of Service In order to identify the types of services to be provided, air ambulance licenses shall be issued for each of the following types of service.

1. Rotor wing advanced life support (RW-ALS)

2. Rotor wing critical care (RW-CC)

3. Rotor wing specialty care (RW-SC)

4. Fixed wing basic life support (FW-BLS)

5. Fixed wing advanced life support (FW-ALS)

6. Fixed wing critical care (FW-CC)

7. Fixed wing specialty care (FW-SC)

13.11 General Operational Requirements 1. Each air ambulance service shall work in coordination with all other air ambulance services to assure optimal minimal response times.

2. Policies for responding to requests for services shall include: A. Consultation with the requesting party regarding how and to whom those flights will be referred, based on the air ambulance service's scope of service, geographical proximity, transport capability and type of call.

B. The closest appropriate service shall be dispatched unless a specific air ambulance service is requested by the requesting party.

C. All air ambulance services must have a communications system in place capable of providing appropriate, timely referrals.

D. Factors affecting the estimated time of arrival (ETA) of air ambulance service shall be communicated to the calling party as soon as possible, within five (5) minutes for inter-facility transports and three (3) minutes for scene requests. E. Scene requests shall be referred within three (3) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available.

F. Inter-facility transport requests shall be referred within five (5) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available. G. Air ambulance service response policies and times shall be available to the public, upon request.

H. In accordance with Section 11 of these rules, Colorado licensed air ambulance services shall complete a patient care report (PCR) to include the minimum pre- hospital care data set for each patient that is transported. The minimum data elements identified by the department shall be compiled and submitted to the department in a format and frequency specified by the department. I. Each licensed air ambulance service shall complete and submit to the department an agency profile to provide information on resources available for planning and coordination of statewide emergency medical and trauma services. 13.12 Complaints Complaints in writing relating to the quality and conduct of any air ambulance service may be made by any person or may be initiated by the department. The department may make inquiry as to the validity of such complaint prior to initiating an investigation. If the department determines that the complaint warrants a more extensive review, an investigation may be initiated. If the complaint does not warrant further review or the inquiry determines that the complaint is not within regulatory jurisdiction of the department, the department will notify the complainant of the results of the inquiry. The department shall refer complaints that are related to the requirements of CAMTS or a successor organization to CAMTS or such successor organization for investigation. The department may forward complaints to other regulatory agencies. 13.13 Denial, Revocation, Suspension, Summary Suspension, or Limitations of Air Ambulance Licenses 1. If the department proposes for good cause to deny, revoke, suspend, summarily suspend or limit the license of an air ambulance service, the department shall notify the air ambulance service of its right to appeal the denial, revocation, suspension, summary suspension, or limitation, and the procedure for appealing. Appeals of departmental denials, revocations, suspensions, summary suspensions, or limitations shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.

2. In accordance with Section 24-4-104(4) C.R.S., the department may summarily suspend an air ambulance service license when the department has objective and reasonable grounds to believe and finds, upon a full investigation, that the holder of the license has been guilty of deliberate and willful violation or that the public health, safety or welfare imperatively requires emergency action by the department. If the department summarily suspends a license, the department shall provide the air ambulance service with notice of such suspension in writing. The notice shall state that the air ambulance service is entitled to a prompt hearing on the matter.

3. Good cause for sanctions include but are not limited to: A. An applicant or licensee who fails to meet the requirements for licensing as set forth in these rules.

B. An applicant or licensee who has committed fraud, misrepresentation, or deception in applying for a license.

C. Falsifying reporting information provided to the department. D. Violating any state or federal statute, rule or regulation that would jeopardize the health or safety of a patient or the public.

E. Unprofessional conduct, which hinders, delays, eliminates, or deters the provision of medical care to the patient or endangers the safety of the public. F. Failure to achieve or maintain CAMTS accreditation.

13.14 General Requirements 1. These rules incorporate by reference the following materials: A. For services whose most recent application for CAMTS accreditation was submitted prior to January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Sixth Edition, published October 2004.

B. For services whose most recent application for CAMTS accreditation is submitted on or after January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Seventh Edition, published September 2006.

C. Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the division by contacting:

EMTS Section Chief Health Facilities and EMS Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 2. These materials have been submitted to the state publications depository and distribution center and are available for interlibrary loans. The incorporated material may be examined at any state publications depository library.

_____________________________________________________ Editor’s Notes History Entire Rule eff. 03/01/2008.

Section 11 eff 05/30/2008.

Sections 1-6 eff. 12/30/2009.