216-RICR-20-10-2 TITLE 216 – DEPARTMENT OF HEALTH CHAPTER 20 – COMMUNITY HEALTH SUBCHAPTER 10 – SCREENING, MEDICAL SERVICES, AND REPORTING PART 2 – Emergency Medical Services 2.1 Authority These Regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws § 23-4.1-10(b), for the purpose of establishing minimum standards for emergency medical services.

2.2 Incorporated Materials A. These Regulations hereby adopt and incorporate HIPAA Privacy Rule and Public Health: Guidance from CDC and the U.S. Department of Health and Human Services May 2, 2003/52 (S-1); 1-12, by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these Regulations.

B. These Regulations hereby adopt and incorporate National Emergency Medical Services Education Standards published by the National Highway and Traffic Safety Administration of the U.S. Department of Transportation, 2009 edition, by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. C. These Regulations hereby adopt and incorporate National Fire Protection Agency (NFPA) 1917 Standard for Automotive Ambulances, 2019 edition, by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. D. These Regulations hereby adopt and incorporate ASTM International E810 Test Method for Coefficient of Retroreflection of Retroreflective Sheeting Utilizing the Coplanar Geometry, 2013 edition, by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.

E. These Regulations hereby adopt and incorporate American National Standard Z535.1, Safety Color Code, 2017 edition, by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.

F. These Regulations hereby adopt and incorporate SAE International J 1849, 2020 edition, by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.

G. These Regulations hereby adopt and incorporate the Federal specification for Star of Life Ambulances (KKK-A-1822(F)) (2018) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.

2.3 Definitions A. Wherever used in these Regulations the following terms shall be construed to mean:

1. "Ambulance" means any publicly or privately-owned vehicle, designed, constructed, equipped, and operated for emergency medical treatment and/or transportation of persons who are sick or injured. 2. "Change of ownership of ambulance service or EMS training institution" means:

a. In the case of a partnership, the removal, addition, or substitution of a partner which results in a new partner acquiring a controlling interest in such partnership;

b. In the case of an unincorporated sole proprietorship, the transfer of the title and property to another person;

c. In the case of a corporation:

(1) A sale, lease, exchange, or other disposition of all, or substantially all, of the property and assets of the corporation; or (2) A merger of the corporation into another corporation; or (3) The consolidation of two (2) or more corporations, resulting in the creation of a new corporation; or (4) In the case of a business corporation, any transfer of corporate stock which results in a new person acquiring a controlling interest in such corporation; or (5) In the case of a non-business corporation, any change in membership which results in a new person acquiring a controlling vote in such corporation.

3. "COVID-19" means the new disease caused by novel coronavirus SARS- CoV-2.

4. "Emergency medical services" or "EMS" means the practitioners, ambulance vehicles, and ambulance service entities licensed to provide emergency medical care, transportation, and preventive care to mitigate loss of life or exacerbation of illness or injury.

5. "Emergency medical services instructor-coordinator" or "EMS IC" means an individual who is licensed both as an EMS practitioner and as an EMS Instructor-Coordinator.

6. "Emergency medical services (EMS) practitioner" means an individual who is licensed to perform emergency medical care and preventive care to mitigate loss of life or exacerbation of illness or injury. 7. "Healthcare provider" means a physician, physician assistant, or certified nurse practitioner licensed to practice in Rhode Island. 8. "Mutual aid" means an agreement among ambulance services to assist one another across jurisdictional boundaries.

9. "National Registry of Emergency Medical Technicians" or "NREMT" means the not-for-profit, independent, non-governmental registration agency which conducts examinations for the certification of EMS practitioners.

10. "RIDOH" means the Rhode Island Department of Health. 11. "Rhode Island Continued Competency Program" or "RI-CCP" means the program that defines how EMS practitioners must accumulate continuing education hours in certain topic areas to meet licensure renewal requirements.

12. "Rhode Island Emergency Medical Services Information System" or "RI- EMSIS" means the central data repository of EMS data for the State of Rhode Island.

13. "Unprofessional conduct" means behavior that does not conform with established standards of clinical care, or behavior that is a violation of statutory and/or regulatory requirements.

14. "Volunteer ambulance service" means a licensed ambulance service that provides services utilizing staff who are volunteer EMS practitioners. 15. "Volunteer EMS practitioner" means a licensed EMS practitioner who provides services without remuneration, other than nominal payment or reimbursements for expenses.

2.4 Confidentiality Provisions A. All information concerning cases or suspected cases shall be held in confidence in accordance with the provisions of R.I. Gen Laws Chapter 5-37.3 "Confidentiality of Health Care Communications and Information Act" and all other applicable State and Federal Statutes and Regulations. B. The HIPAA Privacy Rule and Public Health: Guidance from the CDC and the U.S. Department of Health and Human Services incorporated above expressly permits disclosures without individual authorization to public health authorities authorized by law to collect or receive the information to prevent or control disease, injury, or disability, including, but not limited to, public health surveillance, investigation, and intervention.

2.5 Emergency Medical Services (EMS) Practitioners A. EMS Practitioners shall be licensed at the following levels: 1. Emergency Medical Responder (EMR) means an individual who holds a license to function as an EMR in Rhode Island.

2. Emergency Medical Technician (EMT) means an individual who holds a license to function as an EMT in Rhode Island.

3. Advanced Emergency Medical Technician (AEMT) means an individual who holds a license to function as an AEMT in Rhode Island. 4. Advanced Emergency Medical Technician-Cardiac (AEMT-C) means an individual who holds a license to function as an AEMT-C in Rhode Island. 5. Paramedic means an individual who holds a license to function as a paramedic in Rhode Island.

B. Requirements for initial licensure at all levels of EMS practice: 1. Applicants for licensure to function in Rhode Island in any one (1) of the levels of EMS practitioner must meet the following requirements and provide supporting documentation at the time of application: a. Be eighteen (18) years of age or older.

b. Be a high school graduate or equivalent.

(1) An EMR applicant is exempt from this Rule.

c. Possess current National Registry of Emergency Medical Technicians (NREMT) certification pertinent to the level of licensure being sought.

d. Provide a biometric background check conducted within the last month.

e. Pay the application fee stated in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), if applicable. f. Such other information as RIDOH may require.

2. Additional requirements for initial licensure of AEMT: a. Current licensure as an EMT.

b. Current certification as an Advanced EMT by the NREMT. 3. Additional requirements for initial licensure of AEMT-C: a. Current licensure as an EMT.

b. Successful completion of a RIDOH approved AEMT-C education course.

c. Current certification as an AEMT by the NREMT.

d. Current Advanced Cardiac Life Support (ACLS) certification. 4. Additional requirements for initial licensure of Paramedic: a. Current licensure as an EMT, AEMT or AEMT-C.

b. Current certification as a paramedic by the NREMT.

C. Requirements for renewal of license at all levels of EMS practice: 1. Applicants for licensure renewal in any one (1) of the levels of EMS practitioner must renew prior to the date of its expiration by submitting a completed application form and application fee stated in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), if applicable. 2. Requirements for EMR Practitioner License Renewal An EMR must maintain NREMT certification as an Emergency Medical Responder.

3. Requirements for EMT Practitioner License Renewal a. An EMT licensed after January 1, 2012 must maintain NREMT certification as an EMT.

b. An EMT licensed prior to January 1, 2012 must complete the requirements of the Rhode Island Continued Competency Program (RI-CCP) or maintain NREMT certification as an EMT.

4. Requirements for AEMT Practitioner License Renewal An AEMT must maintain NREMT certification as an AEMT.

5. Requirements for AEMT-C Practitioner License Renewal An AEMT-C must complete the requirements of the RI-CCP, or maintain NREMT certification as an AEMT.

6. Requirements for Paramedic Practitioner License Renewal A paramedic must maintain NREMT certification as a paramedic. D. Requirements for renewal of lapsed EMS practitioner licenses 1. An EMS practitioner whose license has lapsed for a period of less than one (1) year may be relicensed upon submission of a license application and documentation of licensure renewal requirements.

2. An EMS practitioner whose license has lapsed for a period of one (1) to two (2) years may be relicensed upon:

a. Submission of a license application and documentation of licensure renewal requirements; and b. Successful completion of the appropriate NREMT exam or presentation of a current NREMT certification.

3. An EMS practitioner whose license has lapsed for a period of greater than two (2) years will be subject to the requirements for initial license. E. Functions and Responsibilities of EMS Practitioners 1. Each EMS practitioner is authorized to perform functions based upon his or her level of education and licensure solely in affiliation with an ambulance service currently licensed by RIDOH unless providing care as a Good Samaritan. In performing his or her functions and responsibilities, the practitioner must follow standing orders from the medical director for the Center for Emergency Medical Services (CEMS).

a. Notwithstanding any Regulation or statewide protocol to the contrary, specimens to be used to test for active COVID-19 or COVID-19 antibodies, including nasopharyngeal or oropharyngeal specimens, may be collected by EMS practitioners for the duration of the State of Emergency declaration arising out of the 2019 novel coronavirus.

2. Ensure that deficiencies in ambulance equipment are reported to the proper authority.

3. Ensure the ambulance and the equipment are clean, safe, and in proper working condition.

4. Maintain current knowledge of RIDOH Regulations, EMS care protocols, and standing orders.

5. Complete a RIDOH-approved electronic patient care report for all emergency calls.

6. Maintain a current and valid e-mail address on file with the RIDOH licensing system and the Rhode Island EMS Information System. 7. Any additional duties necessary to discharge his or her function as an EMS practitioner 8. All EMS practitioners must report in writing to CEMS within ten (10) days, any of the following:

a. Any felony charge or felony conviction in Rhode Island or any other jurisdiction.

b. Any charge or conviction for driving while intoxicated or under the influence in Rhode Island or any other jurisdiction.

c. Any charge or conviction for driving to endanger in Rhode Island or any other jurisdiction.

F. All EMS practitioners must comply with the pre-employment requirements of the Rules and Regulations pertaining to Immunization, Testing, and Health Screening for Health Care Workers (Subchapter 15, Part 7 of this Chapter). G. Disciplinary Actions 1. In accordance with R.I. Gen. Laws § 23-4.1-9, RIDOH may deny, revoke, or suspend a license or invoke other disciplinary action such as probation or reprimand against any licensee for cause. Cause shall include, but not be limited to, the following:

a. Fraud or deceit in procuring or attempting to procure a license b. Gross negligence in providing medical care c. Impairment due to the use of alcohol or drugs d. Severe mental incompetence due to any cause e. Unprofessional conduct related to current standards of EMS practice f. Violation of any Federal or State law g. Conduct that has aided, abetted, or permitted any illegal act that is detrimental to health and safety h. Performance of emergency medical tasks beyond his or her scope of practice, as defined by education, licensure, and/or standing orders i. Failure to comply with any EMS Statutes and Regulations 2. Appeal from disciplinary actions may be taken pursuant to R.I. Gen. Laws § 23-4.1-9, R.I. Gen. Laws Chapter 42-35, and Practices and Procedures Before the Rhode Island Department of Health (Part 10-05-4 of this Title). 2.6 Emergency Medical Services Instructor-Coordinators (EMS IC) A. Requirements for initial licensure of EMS IC:

1. Certificate of completion from an EMS IC educational program approved by RIDOH. To qualify for admission to an EMS IC Training Program, an applicant must hold a Rhode Island EMS practitioner license for at least five (5) years or have been licensed as an EMS practitioner in another State for at least five (5) years.

2. Successful completion of twenty-four (24) hours of student teaching, which must include five (5) different cognitive sessions and three (3) different psychomotor training sessions, under the direction of at least three (3) different RIDOH-licensed EMS Instructor-Coordinators.

3. Successful completion of a RIDOH EMS IC administrative orientation session.

B. Applicants for EMS IC licensure with a bachelor’s degree or higher in educational studies, or NFPA 1041 fire instructor certification, may submit a request for a waiver to RIDOH from the requirements of the EMS IC educational program. C. Requirements for renewal of EMS IC licensure:

An EMS IC must maintain a current EMS practitioner license and accrue ten (10) hours of EMS IC teaching activity per year.

D. Requirements for renewal of lapsed EMS IC licenses:

1. An EMS IC whose license has lapsed for a period of less than one (1) year may be relicensed upon submission of a license application and documentation of licensure renewal requirements.

2. An EMS IC whose license has lapsed for a period of one (1) to two (2) years may be relicensed upon:

a. Successful completion of twenty-four (24) hours of student teaching, which must include five (5) different cognitive sessions and three (3) different psychomotor training sessions under the direction of at least three (3) different RIDOH-licensed EMS Instructor-Coordinators.

b. Successful completion of a RIDOH EMS IC administrative orientation session.

c. Submission of a license application.

3. An EMS IC whose license has lapsed for a period of greater than two (2) years or longer will be subject to the requirements for initial license. E. Functions and Responsibilities Administer and conduct education programs in accordance with the National Emergency Medical Services Education Standards, 2009 edition, published by the National Highway and Traffic Safety Administration of the U.S. Department of Transportation, incorporated at § 2.2(B) of this Part.

2.7 Ambulance Services A. Ambulance services shall be licensed at the following levels: 1. Class A: Advanced life support (ALS)

2. Class B: Basic life support only (BLS)

3. Class C: EMR B. Requirements for initial and renewal licensure of ambulance services: 1. The applicant for an ambulance service license must be the entity responsible for its governance, and the license is not transferable among entities.

2. A license will immediately become null and void and must be returned to RIDOH when service is discontinued or when any changes in ownership occur pursuant to R.I. Gen. Laws § 23-4.1-6(f).

3. The license must be posted in a conspicuous place in the ambulance service central office.

4. Identify the individual or individuals, which may include existing staff, who fulfill the following functions:

a. Emergency Medical Services Chief of Service: the individual who is the lead administrator of the ambulance service b. Emergency Medical Services Communications Coordinator: the individual who ensures that all communications equipment is functional and meets RIDOH standards c. Emergency Medical Services Continuous Quality Improvement Coordinator: the individual who oversees the quality improvement program in conjunction with the Medical Director of the service d. Emergency Medical Services Coordinator: the individual who directs and coordinates all EMS activities within an ambulance service. This function must be staffed by an emergency medical services practitioner or practitioners in accordance with the level of Emergency Medical Services (pursuant to § 2.8(A) of this Part) provided.

e. Emergency Medical Services Data Manager: the individual who reviews the EMS data for completeness and accuracy, and submits data to RI EMS Information System within the required timeframe f. Emergency Medical Services Inspection Contact: the individual who ensures compliance with inspection requirements g. Emergency Medical Service Pediatric Emergency Care Coordinator (PECC): the individual who ensures that the ambulance service and its providers are prepared to care for ill and injured children h. Emergency Medical Services Training Coordinator: the individual who ensures that all RIDOH, NREMT, and ambulance service training requirements are met i. Emergency Medical Service Medical Director: the individual who is a physician board-certified or board-eligible in emergency medicine and/or EMS 5. Each ambulance service must have written policies and procedures that are consistent with accepted standards of EMS care and standing orders, guidelines for the operation of the service, and the maintenance of the ambulances. These policies must be comprehensive in nature, must reflect day-to-day operations, and must address subjects to include, but not be limited to:

a. The service’s responsibility to ensure all personnel maintain licensure b. An orientation and training plan for all new ambulance service personnel c. Assurance of compliance with pre-employment immunization and testing requirements d. Agreements for mutual aid, including policies for when mutual aid is to be used e. Procedures for dispatching ambulances and related communications including pre-arrival instructions when applicable f. Procedures for stocking medications, supplies, and equipment g. Policies for use of lights and sirens h. Adherence to minimum staffing requirements and duties i. Addressing mechanical failure of vehicles or equipment j. Cooperation with inspection authorities k. Policies for infection control l. Maintenance of mechanical and biomedical equipment and devices in accordance with manufacturers’ recommendations m. Acquisition, security and disposal of controlled substances and other drugs in accordance with applicable Federal and State Regulations n. Resolution of complaints o. Media relations p. Utilization of the National Incident Management System (NIMS) 6. Private ground ambulance services must have the following minimum insurance coverage types and limit requirements at all times. a. General liability insurance with limits of not less than one million dollars ($1,000,000.00) per each occurrence and two million dollars ($2,000,000.00) in the aggregate.

b. Automobile liability insurance with limits of not less than one million dollars ($1,000,000.00) per each accident, and must include all vehicles used by the applicant.

c. Professional liability insurance covering errors and omissions with limits of not less than one million dollars ($1,000,000.00) per each claim and two million dollars ($2,000,000.00) in the aggregate. d. Workers compensation insurance with statutory limits of coverage with employer liability limits of five hundred thousand dollars ($500,000.00) per each accident, disease limits of five hundred thousand dollars ($500,000.00) per each employee, and disease policy limit of five hundred thousand dollars ($500,000.00). 7. Ground ambulance services must have a secure, temperature-controlled garage to house all ambulance vehicles when not in use. 8. Each licensed ambulance service must implement a continuous quality improvement program to assess, monitor, and evaluate the quality of patient care.

9. Pay the application fee stated in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), if applicable.

10. Any other information required by RIDOH C. Availability of Ambulance Services 1. An ambulance service licensed in Rhode Island must be available to provide ambulance services on a twenty-four hour (24) basis, seven (7) days a week.

2. Services must be provided either directly or under a written agreement with other licensed ambulance services. If agreements are made, a copy of the agreement must be submitted to RIDOH.

D. Ambulance Service Reporting Requirements 1. An ambulance service must maintain appropriate personnel and administrative records, and electronic patient care reports. All data must be reported to RIDOH in an electronic format. Records include the following:

a. Evidence of training and continued competency education b. Maintenance records for each licensed ambulance c. Record for each licensed ambulance including a list of equipment, and other essential data d. Maintenance and scheduled service records for medical devices as required by the manufacturer, including cardiac monitors/defibrillators, stretchers, and stair chairs 2. An ambulance service must report changes in administrative staff to RIDOH within five (5) business days.

3. Electronic patient care reports (ePCR)

a. RIDOH-approved electronic patient care reports for all ambulance calls must be completed.

b. All electronic patient care reports must meet the standards of the National Emergency Medical Services Information System (NEMSIS) and the Rhode Island Emergency Medical Services Information System (RIEMSIS). RIDOH will determine the NEMSIS version that is applicable and any State-mandated data fields. c. Electronic patient care reports must be posted to RIEMSIS within two (2) hours of completion of the incident, i.e. transportation to the destination, by the responding EMS personnel.

d. A digital and paper copy of the completed patient care report for each patient transported to a hospital emergency facility must be left with and promptly available to a designated representative of the receiving facility, who will sign the report upon receipt of the patient, indicating a transfer of care. A copy of the patient care report must be retained by the receiving hospital, the ambulance service, and RIDOH.

4. Reportable Events a. An ambulance service must file a written report with RIDOH within seventy-two hours (72) of the following reportable events involving its service, personnel, or property:

(1) Fire affecting an ambulance or service place of business (2) Theft of an ambulance (3) Loss, theft or tampering with any controlled substances, drug delivery devices, or other regulated medical devices and equipment from an agency facility or ambulance (4) An accident involving personal injury or property damage more than one thousand dollars ($1,000.00) and in which a report is required under the provisions of R.I. Gen. Laws § 31-26-6 (5) Kidnapping or elopement of a patient (6) More than a thirty minute (30) delay between the time of arrival at a healthcare facility and transfer of care to a healthcare provider at the receiving facility (7) Pending or actual labor disputes or actions which would impact delivery of EMS services including, but not limited to, strikes, walk-outs and strike notices. Services must provide a plan, acceptable to the RIDOH, for continued operation of the service, suspension of operations, or closure in the event of such actual or potential labor dispute or action.

5. Reportable Incidents a. An ambulance service must file a written report with RIDOH within five (5) days of the following reportable incidents involving its service, personnel, or property that result in serious injury, illness or death to a patient not ordinarily expected as a result of the patient’s condition. These incidents include, but are not limited to, the following:

(1) Medication errors (2) Deviation from medical standing orders (3) Major medical device failures (4) Major communications device failures 6. Ambulance Service Closure a. An ambulance service must inform RIDOH in writing of its intent to close at least ninety (90) days prior to its closure.

b. The ambulance service must develop a written closure plan to include:

(1) The date the agency will cease operations (2) Steps to ensure adequate staffing throughout the closure process (3) A process for the disposition of properties, vehicles, equipment, supplies, and assets (4) Steps to dispose of any pharmaceutical, biological, and chemical products and waste (5) A process to assure transfer of any contracts to another ambulance service after closure E. Controlled substances 1. An ambulance service licensed as Class A-1C, A-1P, A-2C or A-2P Advanced Life Support must maintain current registration with: a. RIDOH, in accordance with the Rhode Island Uniform Controlled Substances Act, R.I. Gen Laws Chapter 21-28, and b. U.S. Department of Justice Drug Enforcement Administration. 2.8 Ambulance Vehicles A. Ambulance vehicles shall be licensed at the following classifications: 1. Class A-1C: Advanced Life Support transporting ambulance 2. Class A-1P: Advanced Life Support transporting ambulance, paramedic level 3. Class A-2C: Advanced Life Support non-transporting ambulance 4. Class A-2P: Advanced Life Support non-transporting ambulance, paramedic level 5. Class A-2A: Advanced Life Support non-transporting ambulance, advanced EMT level 6. Class B-1: Basic Life Support transporting ambulance 7. Class B-2: Basic Life Support non-transporting ambulance 8. Class C: Advanced Life Support: Air Medical Services B. Requirements for initial and renewal licensure for all classifications of ambulance vehicles:

1. The applicant for an ambulance vehicle license must be the entity responsible for its governance, and the license is not transferable among entities or vehicles.

2. A license will immediately become null and void and must be returned to RIDOH when service is discontinued or when any changes in ownership occur pursuant to R.I. Gen. Laws § 23-4.1-6(f).

3. A license must be posted in a conspicuous place in the ambulance. 4. The ambulance must comply with the equipment and supply requirements in § 2.12 of this Part.

5. Any deficiencies cited in the initial or any other inspection must be corrected before a license will be issued or renewed.

6. Pay the application fee stated in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), if applicable.

7. Any other information required by RIDOH C. Requirements for initial and renewal licensure for all classifications of transporting ambulance vehicles in class A-1C, A-1P, and B-1: 1. A newly manufactured ambulance vehicle must conform to the Federal Specification for Star of Life Ambulances (KKK-A-1822(F)), incorporated at § 2.2(G) of this Part, and/or the National Fire Protection Agency (NFPA) 1917 Standard for Automotive Ambulances, 2019 edition, incorporated at § 2.2(C) of this Part, as of the date of the original purchase order. Remounted ambulances shall be considered a newly manufactured ambulance vehicle.

2. An ambulance vehicle must be identified with the name of the service prominently lettered on both sides and the rear of the vehicle. 3. The material for the emblems and markings must be applied using reflective material that has a coefficient of retro-reflection measured in accordance with ASTM International E810 Test Method for Coefficient of Retroreflection of Retroreflective Sheeting Utilizing the Coplanar Geometry.

4. The reflective color used shall be blue, color a, and white, color i, in accordance with the American National Standard Z535.1, Safety Color Code. They must comply with the tolerances expressed in terms of Munsell hue, value, and chroma.

5. For a newly manufactured ambulance vehicle, the emblems and markings shall be of the type, size, color, and location as follows: a. Only ambulance vehicles licensed as Advanced Life Support Class A-1C, A-1P, A-2C, A-2P, A-2A or C may be identified by lettering or any other means as "Advanced Life Support" or any similar designation.

b. Front markings: the word “AMBULANCE” or “RESCUE” in mirror image, in block, blue, die cut style letters, not less than four inches (4") high, centered above the grille. The placement of the word “AMBULANCE” or “RESCUE” on the curved surface of the hood or on a flat plastic type bug screen is permitted. A Star of Life in three inch (3") blue, die cut style, with a white border must be located both to the right and left of the word “AMBULANCE” or “RESCUE.” c. Side markings: each side of the ambulance must be marked with one (1) Star of Life emblem not less than sixteen inches (16") in blue, die cut style with a white border.

d. Rear markings: the rear of the ambulance must be marked with two (2) Star of Life emblems not less than ten inches (10"), in blue, die cut style with a white border.

e. Roof marking: a Star of Life of not less than thirty-two inches (32") in blue, die cut style, which may be without the white Staff of Asclepius, must be provided on the ambulance rooftop.

D. Requirements for initial and renewal licensure for all classifications of non- transporting ambulance vehicles in Class A-2C, A-2P, A-2A, or B-2: 1. Be equipped with a warning device, such as a mechanical siren or electric penetrating unit, which is audible five hundred feet (500’) to the front 2. Be equipped with red, flashing, warning lights 3. Be designed to safely and adequately house required medical equipment and supplies 4. Be marked with one (1) Star of Life emblem not less than eight inches (8"), in blue, die cut style with a white border located on one (1) side of the vehicle 5. Be equipped with an audible backup warning device, activated when the vehicle is shifted into reverse gear. The device must be rated SAE International J 1849 for 97 dB-a at four feet (4’).

E. Requirements for all Categories of Ambulance Vehicles: 1. An ambulance vehicle can be designated as a reserve vehicle. Reserve ambulance vehicles must have a current Rhode Island Department of Transportation (RIDOT) inspection sticker. A listing of all required equipment not stocked at the time of inspection must be maintained in the vehicle, and the equipment must be placed in the vehicle when the ambulance is placed into service.

2. An ambulance vehicle must have current Rhode Island Division of Motor Vehicles (RIDMV) and RIDOT inspection stickers.

3. An ambulance vehicle must be maintained in good repair and in safe operating condition at all times.

4. The interior of an ambulance vehicle, including equipment and supplies, must be maintained in accordance with environmental infection control practices to prevent transmission of disease from patient to EMS practitioner, as well as from patient to patient between runs. 5. A licensed EMS practitioner who utilizes latex gloves must do so in accordance with the provisions of the Rules and Regulations pertaining to the Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department (Subchapter 15, Part 3 of this Chapter). F. Staffing Requirements for Ambulance Vehicles:

1. Each class of ambulance must be staffed by Emergency Medical Services practitioners in accordance with the level of Emergency Medical Services provided.

a. Class A-1C or A-1P ambulances must be staffed at all times when providing patient care, by at least two (2) practitioners: (1) One (1) ALS practitioner, such as an AEMT-C or a paramedic, who must remain with the patient while providing advanced life support measures during transportation, and an EMT, AEMT-C, or paramedic (2) In accordance with R.I. Gen. Laws § 23-1-1, volunteer ambulance services must make every attempt to meet the above standards to provide ALS care; however, if these standards cannot be met, the ambulance must be staffed by at least one (1) AEMT-C or one (1) paramedic, who must remain with the patient during transport, and one (1)

Emergency Medical Responder (EMR). All initially responding personnel must be functioning in a volunteer capacity.

b. Class B-1 ambulances must be staffed by at least two (2) EMTs, one (1) of whom may be the driver, the other to remain with the patient during transport.

(1) In accordance with R.I. Gen. Laws § 23-1-1, a volunteer ambulance service must make every attempt to meet the above standards to provide BLS care; however, if these standards cannot be met, the ambulance must be staffed by at least one (1) EMT, who must remain with the patient during transport. All initially responding personnel must be functioning in a volunteer capacity.

c. Class A-2 ambulances must be staffed by at least one (1) AEMT, one (1) AEMT-C, or one (1) paramedic to provide ALS, or one (1) EMT to provide BLS.

d. Class B-2 ambulances must be staffed by at least one (1) EMT, AEMT, AEMT-C or paramedic.

2.9 Exceptions to Licensure Requirements A. Any ambulance service, ambulance vehicle, or EMS practitioner licensed or certified in another U.S. State or Territory that enters Rhode Island in response to a call for assistance from a Rhode Island-licensed ambulance service or RIDOH in a mass casualty/major incident situation, shall be exempt from the provisions of these Regulations requiring licensure.

B. Any individual enrolled in an EMS practitioner education course, functioning under the direct supervision of a licensed health care professional, shall be exempt from the provisions of these Regulations requiring licensure. 2.10 Licensing Requirements for EMS Training Institutions A. EMS training institutions shall be licensed at the following levels. A licensed EMS training institution can conduct training courses at the level of licensure or below. 1. Paramedic 2. Advanced Emergency Medical Technician-Cardiac (AEMT-C) 3. Advanced Emergency Medical Technician (AEMT)

4. Emergency Medical Technician (EMT)

5. Emergency Medical Responder (EMR)

B. Requirements for initial and renewal licensure of EMS training institutions: 1. An EMS training institution applicant must be the entity responsible for its governance, and the license is not transferable among entities. 2. A license will immediately become null and void and must be returned to RIDOH when an EMS training institution is closed or when any changes in ownership occur.

3. A license must be posted in a conspicuous place in the EMS training institution’s central office.

4. An EMS training institution applicant must provide a list of the following administrative staff:

a. Program Director: the individual responsible for the administration, organization, and supervision of the educational program. The Program Director must have the following qualifications: (1) Hold a license as a Rhode Island EMS Instructor- Coordinator and hold a license at or above the level of instruction (2) Have an Associate’s degree from an accredited institution of higher education if conducting EMT or Advanced EMT- Cardiac courses, or a Bachelor’s degree from an accredited institution of higher education if conducting Paramedic programs b. Medical Director: the individual who is a physician who is board- certified or board-eligible in emergency medicine and/or EMS by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine who oversees the program, evaluates and approves all instructors, and remains available for consultation during the training course. The Medical Director must be licensed to practice medicine in Rhode Island. c. Faculty: the individuals who are responsible for all aspects of didactic and clinical instruction d. Clinical Coordinator: the individual responsible for coordinating practicum experiences in hospitals or other healthcare settings e. Field Internship Coordinator: the individual responsible for coordinating practicum experiences in EMS Ambulance Service settings 5. An EMS training institution applicant must have written curriculum, policies, and procedures that are consistent with the National EMS Education Standards.

6. An EMS training institution applicant must maintain current written agreements and/or contracts for clinical and field internships. 7. An EMS training institution applicant must have an official affiliation with one (1) of the following:

a. Four (4) year college or university;

b. Two (2) year technical or community college;

c. Hospital or medical center;

d. Federal, State, county, or local government entity; or e. A public or private corporation that meets State and local business requirements.

8. An EMS training institution applicant must be located in Rhode Island. 9. An EMS training institution applicant must pay the application fee stated in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 10. An EMS training institution applicant must provide any other information required by RIDOH.

C. EMS Training Institution Operational Requirements:

1. An EMS training institution must maintain appropriate student, personnel, and administrative records, including but not limited to, student admission, advisement, counseling, and evaluation.

2. An EMS training institution must annually self-evaluate or review the following:

a. Instructor performance b. Course completion and pass rates c. NREMT pass rates d. Student evaluations of instructors and program 3. An EMS training institution must submit a report summarizing the self- evaluation described in § 2.10(C)(2) of this Part annually, by March 1st of the following calendar year.

4. EMS training institutions must maintain sufficient program resources, including but not limited to the following:

a. Finances b. Classroom and laboratory facilities c. Equipment and supplies d. Computers e. Instructional reference materials 5. An EMS training institution must have clear syllabi with policies detailing the following:

a. Class attendance b. Student behavior c. Sexual and other forms of harassment d. Appearance and attire e. Grade determination f. Academic honor code g. Academic calendar h. Student grievance procedure i. Criteria for successful completion of each segment of the curriculum and graduation j. Policies and processes by which students may perform clinical work while enrolled in the program 6. An EMS training institution must implement a continuous quality improvement program to assess, monitor, and evaluate the quality of its instructional programs and continuing education of its faculty. 7. An EMS training institution must report changes in administrative staff to CEMS within five (5) business days.

8. Any other information required by RIDOH to determine compliance with the standards of this Part.

2.11 Variances A. An application for variance from the requirements of this Part must be made in writing to RIDOH. Licensing requirements are not eligible for consideration of a variance.

B. The variance application must demonstrate that a literal enforcement of these Rules will result in an unnecessary hardship to the applicant and that such a variance will not be contrary to the health and safety of the public. 2.12 Minimum Equipment Requirements for Ambulance Vehicles A. The following list indicates the minimum equipment required for each class of ambulance vehicle license.

R = Required O = Optional X = Not permitted Section 1: General Requirements Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Communication Two-way voice R R R R R R R R with dispatcher communications Communication Two-way voice R R R R R R O R with hospital communications Complete tool R R R R R R R X Minimum of: one kit (1) open-end adjustable wrench at least twelve inches (12”); one (1)

screwdriver regular blade at least eight inches (8”); one (1) screwdriver, Phillips type at least eight inches (8”); one (1) hacksaw with three (3) blades;

one (1) pliers, vise-grip type;

one (1) three (3)

pound hammer;

one (1) crowbar at least twenty- four inches (24”)

or halligan tool;

one (1) battery cable cutter; two (2) ropes, at least one half inch (½”)

diameter, fifty feet (50’) long;

two (2) pairs safety goggles;

two (2) pairs work gloves; two (2) reflective vests/garments or equivalent, ANSI 207-2011 compliant; two (2) flashlights with batteries.

Controlled R R R R X X X R Log of all substance log controlled book substances carried, including lot numbers, total dose given per call, incident number, hospital replacement, and any wastage.

Logbook must be hardcover, bound, and have numbered pages Stored securely Controlled with at least two substance R R R R X X X R (2) locks, keyed security or combination DOT inspection R R R R R R R X Rhode Island sticker DOT R R R R R R R X Rhode Island registration Emergency R R R R R R R X Per NFPA 1917 lights Equipment R R R R R R R R All supplies, properly equipment, secured tools, etc. shall be stored in enclosed compartments or fastened to secure them during vehicle motion.

Equipment weighing three (3) lbs. or more mounted or stored in a driving or patient area shall be contained in an enclosed compartment capable of containing the contents when a ten (10) G force is applied in the longitudinal, lateral, or vertical axis of the vehicle, if the equipment is secured in a bracket or mount that can contain the equipment when the equipment is subjected to those same forces.

Exhaust system R R R R R R R X Fire R R R R R R R R Vehicle shall be extinguishers equipped with at least two (2)

mounted and charged fire extinguishers, dry chemical, each with a capacity of five (5) lbs. or greater, approved by Underwriter’s Laboratory (UL), with at least one (1) mounted in the patient compartment of transporting ambulances.

Free from R R R R R R R R rust/dents Non-emergency R R R R R R R R exterior lighting Patient compartment R R X X X R X R Per NFPA 1917 lighting PTS and ePCR capable laptop computer or tablet and all ancillary equipment and supplies including a docking station, bar code scanner, Patient tracking R R O O O R O R tracking system/ePCR bracelets and triage tags and all shall be in good working condition. The ePCR software must be RI CEMS approved. The service shall also maintain a viable data connectivity plan.

RI Statewide R R R R R R R R EMS Protocols Siren R R R R R R R X Per NFPA 1917 Minimum of Triage/tracking R R R R R R R R twenty-five (25)

tags triage tags Minimum of Triangle R R R R R R R R 3A9A3:J22A2:J2 reflectors A2:J22 Section 2: Basic Life Support Supplies and Equipment Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Minimum of six Antiseptic wipes R R R R R R R R (6)

Adhesive tape R R R R R R R R One (1) meter Blood glucose with minimum of R R R R R R R R meter five (5) test strips Adult, child, Blood pressure R R R R R R R R infant, large cuffs adult sizes Cold packs R R R R R R R R Minimum of three (3)

Conforming Minimum of six R R R R R R R R bandages (6)

Minimum of two Chest seal R R R R R R R R (2) commercially dressing prepared units Minimum of two Hypothermia R R R R R R R R (2) Mylar blanket blankets Mucosal Minimum of two atomization R R R R R R R R (2)

device Minimum of one Obstetrics kit R R R R R R R R (1)

Pediatric dosing Minimum of one R R R R R R R R device (1)

Minimum of one Pelvic binder R R R R R R R R (1) adult size Minimum of two (2) to fit adult Splints R R R R R R R R and pediatric patients Sterile burn Minimum of two R R R R R R R R sheets (2)

Gauze pads in Sterile gauze R R R R R R R R assorted sizes Sterile water R R R R R R R R Minimum of one (1) liter Minimum of one Stethoscopes R R R R R R R R (1) adult and one (1) pediatric Minimum of two (2) in each size:

ten (10) mL, five (5) mL, one (1)

Syringes/ R R R R R R R R mL; one (1) sixty needles (60) mL and two (2) one and one half inch (1-1/2”)

needles Minimum of one (1) with a range of at least seventy-eight (78.0º F) to one Thermometers R R R R R R R R hundred and eleven and nine tenths degrees Fahrenheit (111.9º F)

Minimum of four (4), Tourniquet R R R R R R R R commercially prepared Minimum of one Traction splint R R O O O R O R (1) adult size Trauma Minimum of R R R R R R R R dressings three (3)

Minimum of one Trauma shears R R R R R R R R (1)

Triangular Minimum of R R R R R R R R bandages three (3)

Minimum of Water soluble R R R R R R R R three (3)

lubricant packets Section 3: Extrication and Transportation Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Minimum of one (1) in each size Cervical collars R R R R R R R R to fit infants through tall adults Minimum of one (1) child restraint seat fitting children weighing from twenty (20) to forty (40) lbs.

The seat must be capable of Child seat R R O O O R O R being secured to the vehicle’s stretcher. Seat must be compliant with current Federal Motor Vehicle Safety Standards requirements Long spine Minimum of one R R O O O R O R board (1)

Patient Minimum of one movement R R R R R R R R (1)

device Minimum of one Stair chair R R O O O R O O (1)

Minimum of four Straps for long (4), seven feet R R O O O R O R spine board (7’) to nine feet (9’) in length Stretcher/straps R R X X X R X R Stretcher having /mattress a mattress at least three inches (3”) thick with a waterproof non- porous covering.

Stretcher must be equipped with appropriate patient restraints: three (3) mounted leg/torso straps, and two (2)

shoulder straps tethered together at stretcher frame.

Patient restraints shall be compliant with all Federal Motor Vehicle Safety Standards and shall incorporate metal to metal quick release buckles, be not less than two inches (2”) wide, and fabricated from nylon or other materials easily cleaned and disinfected.

A fold down, rigid, telescoping I.V.

pole and holder shall be provided on the left side of stretcher.

Stretcher must operate according to manufacturer’s standards and be current on maintenance and servicing as prescribed by the manufacturer.

All stretchers should only be used with the required fastener assembly and patient restraint as prescribed by the manufacturer.

Section 4: Airway and Ventilation Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Minimum of one (1) of the following advanced airway device kits: LMA kit that includes, at a minimum, LMA sizes 1, 2, 3, 4 and 5; LT/LTS kit that includes, Advanced at a minimum, airway device R R R R R R R R LTA sizes 2, 2.5, kits 3, 4 and 5; I-gel airway kit that includes, at a minimum, I-gel sizes 1, 1.5, 2, 2.5, 3, 4, and 5;

AirQ airway kit that includes, at a minimum, AirQ airway sizes 0.5, 1, 1.5, 2.0, 2.5, 3.5, and 4.5.

Minimum of one Bag-valve- (1) in adult, R R R R R R R R masks pediatric and infant sizes Colorimetric Minimum of one advanced (1) adult and airway R R R R R R R R one (1) pediatric verification sized device devices Continuous R R R R R R R R Minimum of one positive airway (1) assembly to pressure include a flow generator, tubing and a minimum of one (1) small, medium and adult sized mask Main oxygen R R O O O R O R Per NFPA 1917 supply Minimum of four Nasopharyngea R R R R R R R R (4), sized 16-34 l airways French On-board R R O O O R O R Per NFPA 1917 suction Minimum of Oropharyngeal three (3) in R R R R R R R R airways small, medium and large sizes Minimum of one Oxygen R R R R R R R R (1) in adult and cannulas pediatric sizes Minimum of two (2) each in adult Oxygen masks R R R R R R R R and pediatric sizes Oxygen Minimum of two R R R R R R R R nebulizer (2)

Portable oxygen R R R R R R R R Minimum of one cylinder (1) size D or larger with flow meter capable of delivering one to fifteen (1 to 15)

liters per minute of oxygen Portable suction Minimum of one unit, battery R R O O O R O R (1)

powered Portable suction Minimum of one O O R R R O R O unit, manual (1)

Minimum of one Pulse oximeter R R R R R R R R (1)

Minimum of two (2) rigid catheters and Suction two flexible catheters and R R R R R R R R catheters, one tubing (1) between 6- 10 French and one (1) between 12-16 French Tongue Minimum of one R R R R R R R R depressors (1)

Section 5: Infection Control Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Minimum of one Biohazard bag R R R R R R R R (1)

Body substance R R R R R R R R Minimum of one isolation kits (1) per crew member to include a gown, protective goggles, one (1)

pair of disposable gloves, a mask, a head cover and a biohazard bag Latex-free R R R R R R R R Multiple sizes gloves Minimum of one N95 respirators R R R R R R R R (1) per crew member Sharps Minimum of one R R R R R R R R receptacle (1)

Section 6: Cardiac Care Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Approved by the U.S. Food and Drug Administration.

Minimum of one (1) with a fully charged battery and a minimum Automated of one (1) set of external O O O O R R R O one (1) adult defibrillator defibrillation pads. A minimum of one (1) set of pediatric defibrillation pads or dosing attenuation device.

Approved by the U.S. Food and Drug Administration.

Capable of biphasic manual defibrillation, synchronized cardioversion, rhythm waveform display, 12 lead electrocardiogra m acquisition, telemetry, and transcutaneous pacing.

Minimum of one Cardiac monitor (1) with a fully R R R R X X X R and defibrillator charged battery and a minimum of one (1) set of one (1) adult defibrillation pads. A minimum one (1) set of pediatric defibrillation pads or dosing attenuation device.

Functional strip chart recorder.

Electrodes to acquire electrocardiogra ms Section 7: Advanced Life Support Supplies and Equipment Item A-1C A-1P A-2C A-2P A-2A B-1 B-2 C Description Constricting Minimum of two R R R R R X X R bands (2)

Cricothyrotomy Minimum of one X R X R X X X X kit (1)

Endotracheal Minimum of one O R O R X X X O intubation kit (1)

Intraosseous Minimum of one R R R R R X X R infusion device (1)

IV catheters in Minimum of two assorted sizes R R R R R X X R (2) in each size 14-24G IV drip sets ten Minimum of two to fifteen (10 to R R R R R X X R (2)

15) drops Minimum of one (1) with capacity IV fluid warmer R R O O O X X R to hold two (2)

one (1) liter IV bags IV infusion Minimum of one X R X R X X X O pump (1)

Minimum of one Morgan lens X R X R X X X O (1)

Minimum of Nasogastric three (3) in sizes X R X R X X X X tubes between 8-18 French Padded arm Minimum of one R R R R R X X R boards (1)

Minimum of one Pleural (1), and four (4)

decompression X R X R X X X X decompression kit needles Stopcock, 3- or Minimum of one R R R R R X X R 4-way (1)

Volumetric Minimum of one burette, one (1)

R R R R R X X R hundred (100)

mL B. If one (1) or more of the critical deficiencies listed below are noted upon inspection, the vehicle must not operate until all deficiencies are corrected, as applicable.

1. Automated external defibrillator 2. Bag-valve-masks 3. Biohazard bag 4. Blood pressure cuffs 5. Cardiac monitor and defibrillator 6. Cervical collars 7. Communication with dispatcher 8. Communication with hospital 9. DOT registration 10. Emergency lights 11. Equipment properly secured 12. IV catheters in assorted sizes 14-24G 13. IV drip sets ten to fifteen (10 to 15) drops 14. Latex-free gloves 15. Main oxygen supply 16. Nasopharyngeal airways 17. On-board suction 18. Oropharyngeal airways 19. Oxygen masks 20. Oxygen nebulizer 21. Patient Tracking System and ePCR 22. Portable oxygen cylinder 23. Portable suction unit 24. Sharps receptacle 25. Siren 26. Stair chair 27. Stethoscopes 28. Stretcher/straps/mattress 29. Suction catheters and tubing 30. Medications in minimum quantities per the state formulary, unless a national shortage exists for a particular medication.

C. When applicable, equipment and supplies must be sealed, clean, unopened, and in the original manufacturer’s packaging.

216-RICR-20-10-2 TITLE 216 - DEPARTMENT OF HEALTH CHAPTER 20 - COMMUNITY HEALTH SUBCHAPTER 10 - SCREENING, MEDICAL SERVICES, AND REPORTING PART 2 - EMERGENCY MEDICAL SERVICES Type of Filing: Amendment Agency Signature _______________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date __________________________________________________________________ Department of State Initials Department of State Date