1. (a) Application requirements for an Emergency Medical Services (EMS) Provider License.

   1. (1) Candidates for an EMS provider license shall submit a completed application (application, all other required information described in a provider licensing instruction document provided by the Texas Department of Health (department) and a nonrefundable fee) to the department.
   2. (2) A nonrefundable application fee of $500 per provider plus $180 for each EMS vehicle to be operated under the license shall accompany the application. The department will implement the fee requirement for initial applicants on June 1, 2004, and at the time of the next re-license period of currently certified licensed providers following adoption. The license is issued for two years. Fees are required every two years with the license renewal.
   3. (3) If an air ambulance provider advertises in Texas and operates an air ambulance service, the provider shall be required to have a Texas EMS Provider License.
   4. (4) A fixed-wing or rotor-wing air ambulance provider, appropriately licensed by the state governments of New Mexico, Oklahoma, Arkansas or Louisiana may apply for a reciprocal issuance of a provider license. A nonrefundable administrative fee per provider of $500 shall accompany the application in addition to a nonrefundable fee of $180 for each EMS aircraft to be operated in Texas under the reciprocal license.
   5. (5) Applicants who have no more than five full-time paid medical and support staff, or the full-time equivalent, and who operate with at least 75% volunteer personnel, are exempt from the payment of fees.

2. (b) Licenses and Designations. Candidates who meet all the criteria for licensure shall be issued a provider license. Licenses may be issued for less than two years for administrative purposes. Licensed EMS providers (providers) shall comply with all requirements of their license at all times.

   1. (1) Licenses. Providers shall be issued a license for a specific number of vehicles. Copies of the license shall be prominently displayed in a public area of the provider's headquarters and in the patient compartment of each of the provider's vehicles.

   2. (2) Designations. The provider will indicate to the department the number of vehicles designated at each level. Designations are not required to be dedicated to a particular vehicle. A designation at one of the following levels shall be prominently displayed in the patient compartment of each vehicle:

      1. (A) Basic Life Support (BLS);
      2. (B) BLS with Advanced Life Support (ALS) capability;
      3. (C) BLS with Mobile Intensive Care Unit (MICU) capability;
      4. (D) ALS;
      5. (E) ALS with MICU capability;
      6. (F) MICU;

      7. (G) MICU Air:

         1. (i) Rotor wing; or
         2. (ii) Fixed wing; and
      8. (H) specialized.
3. (c) Transfer of licenses and designations. Licenses and designations are not transferable between providers.

4. (d) Vehicles.

   1. (1) All EMS vehicles must be adequately constructed, equipped, maintained and operated to render patient care, comfort and transportation safely and efficiently. EMS vehicles must allow the proper and safe storage and use of all required equipment, supplies and medications and must allow all required procedures to be carried out in a safe and effective manner. Unless otherwise approved by the department, ground vehicles must conform to one of the body types generally recognized as Type I, II, or III.
   2. (2) When response-ready or in-service, EMS vehicles shall have operational two-way communication capable of contacting appropriate medical resources, and shall be in compliance with all applicable state and/or federal laws and; except for fixed wing aircraft shall have the name of the provider prominently displayed on both sides of the vehicle. Licensed providers who operate rotor or fixed wing aircraft must comply with all requirements of §157.12 of this title (relating to Rotor-wing Air Ambulance Operations) or §157.13 of this title (relating to Fixed-wing Air Ambulance Operations).

   3. (3) Substitution, replacement and additional vehicles.

      1. (A) If a provider substitutes or replaces a vehicle, there is no fee, but the department shall be notified within 10 days.
      2. (B) If a provider adds a vehicle to the fleet, a nonrefundable fee is required and the department shall be notified within 10 days of the designation assigned to the vehicle.

5. (e) Required Minimum Staffing.

   1. (1) BLS - when response-ready or in-service - two emergency care attendants (ECA)'s.
   2. (2) BLS with ALS capability - when response-ready or in-service below ALS - two ECA's. Full ALS status becomes active when staffed by at least an emergency medical technician (EMT)-Intermediate and at least an EMT.
   3. (3) BLS with MICU capability - when response-ready or in-service below MICU - two ECA's. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.
   4. (4) ALS - when response-ready or in-service - one EMT-Intermediate and one EMT.
   5. (5) ALS with MICU capability - when response-ready or in-service below MICU - one EMT-Intermediate and one EMT. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.
   6. (6) MICU - when response-ready or in-service - one certified or licensed paramedic and one EMT.
   7. (7) Specialized - when response-ready or in-service - two certified or licensed personnel, certification or licensure level determined by the type and application of the vehicle and approved by the medical director.
   8. (8) For air ambulance staffing requirements refer to §157.12(f) of this title or §157.13(g) of this title.
   9. (9) As justified by patient needs, providers may utilize appropriately certified and/or licensed medical personnel in addition to those which are required by their designation levels. In addition to the care rendered by the required staff, the provider shall be accountable for care rendered by any additional personnel.
6. (f) Protocols. The provider shall submit protocols approved by the provider's medical director identifying procedures for each EMS certification or license level utilized by the provider. Protocols shall also address the use of non-EMS certified or licensed medical personnel who, in addition to the EMS staff provide patient care on behalf of the provider and/or in the provider's EMS vehicles. Physicians, nurses, and other health care practitioners who regularly provide patient care in EMS vehicles shall be EMS certified. The protocols shall address the use of all required, additional, and specialized medical equipment carried by any EMS vehicle in the provider's fleet. Protocols shall have an effective date and an expiration date which corresponds to the effective and expiration dates of the provider's EMS license, and shall indicate specific applications including geographical area and duty status of personnel. For patient care reasons and with appropriate consideration from the medical director, a provider's protocols may be expanded or overridden by on-line medical control, off-line medical direction or by patient-specific orders.
7. (g) Equipment and supplies. The provider shall submit an equipment and supply list which is approved by the medical director and which is consistent with, and fully supportive of, the protocols. The list shall specify an adequate variety of sizes and types and shall specify quantities appropriate to the provider's call volume, transport times and restocking capabilities. All equipment and supplies shall be clean and in working order. During unannounced inspections consideration will be given to equipment and supply deficiencies caused by recent or repeated EMS calls.
8. (h) The requirements for air ambulance equipment and supplies are listed in §157.12(h) of this title or §157.13(h) of this title.

9. (i) At least the following equipment and supplies shall be present on each in-service vehicle and on, or immediately available for, each response-ready vehicle at all times:

   1. (1) BLS:

      1. (A) oropharyngeal airways;
      2. (B) portable and vehicle mounted suction;
      3. (C) bag valve mask units, oxygen capable;
      4. (D) portable and vehicle mounted oxygen;
      5. (E) oxygen delivery devices;
      6. (F) dressing and bandaging materials;
      7. (G) rigid cervical immobilization devices;
      8. (H) spinal immobilization devices;
      9. (I) extremity splints;
      10. (J) equipment to meet special patient needs;
      11. (K) equipment for determining and monitoring patient vital signs, condition or response to treatment;
      12. (L) medications as required by protocols;
      13. (M) Automatic External Defibrillator (AED) or equivalent; and
      14. (N) patient transport device capable of being secured to the vehicle.

   2. (2) ALS or BLS with ALS capability:

      1. (A) all required BLS equipment;
      2. (B) advanced airway equipment; and
      3. (C) IV equipment and supplies.

   3. (3) MICU, BLS with MICU capability, ALS with MICU capability:

      1. (A) all required BLS and ALS equipment; and
      2. (B) cardiac monitor/defibrillator (in lieu of AED).

   4. (4) In addition to medical supplies and equipment:

      1. (A) protocols approved by the current medical director;
      2. (B) emergency warning devices;

      3. (C) personal protective equipment for the crew to include at least:

         1. (i) protective, non-porous gloves;
         2. (ii) medical eye protection;
         3. (iii) medical respiratory protection;
         4. (iv) medical protective gowns or equivalent; and
         5. (v) personal cleansing supplies;
      4. (D) sharps container;
      5. (E) biohazard bags;
      6. (F) fire extinguisher; and
      7. (G) no smoking signs.
   5. (5) As justified by specific patient needs, and when qualified personnel are available, providers may appropriately utilize equipment in addition to that which is required by their designation levels. Equipment used must be consistent with protocols and/or patient-specific orders and must correspond to personnel qualifications.

10. (j) National accreditation. If a provider has been accredited through a national accrediting organization approved by the department and adheres to Texas staffing level requirements, the department may exempt the provider from portions of the license process. In addition to other licensing requirements, accredited providers shall submit:

    1. (1) an accreditation self-study;
    2. (2) a copy of formal accreditation certificate; and
    3. (3) any correspondence or updates to or from the accrediting organization which impact the provider's status.

11. (k) Subscription or Membership Services. An EMS provider who operates or intends to operate a subscription or membership program for the provision of EMS within the provider service area shall meet all the requirements for an EMS provider license as established by the Health and Safety Code, Chapter 773, and the rules adopted thereunder, and shall obtain department approval prior to soliciting, advertising or collecting subscription or membership fees. In order to obtain department approval for a subscription or membership program, the EMS provider shall:

    1. (1) have a written authorization from the bureau chief elected official of the governmental entity for the provision of subscription emergency prehospital care within that governmental service area;
    2. (2) submit a sample of the contract for subscription service, membership and/or the application used to enroll participants;
    3. (3) submit a copy of all advertising used to promote the subscription service at the time of application for each license period. The EMS provider shall maintain a current file of all advertising for the service;
    4. (4) comply with all state and federal regulations regarding billing and reimbursement for participants in the subscription service;

    5. (5) provide evidence of financial responsibility by:

       1. (A) obtaining a surety bond payable to the department in an amount equal to the funds to be subscribed. The surety bond must be issued by a company licensed by or eligible to do business in the State of Texas; or
       2. (B) submitting satisfactory evidence of self insurance if the provider is a function of a governmental entity;
    6. (6) not deny EMS to nonsubscribers or subscribers of noncurrent status;.
    7. (7) be reviewed at least every two years when the provider license is renewed; and the subscription program may be reviewed by the department during spot inspections;
    8. (8) furnish the names and addresses of all subscribers/members to the department at the beginning of each licensure period in a format mutually acceptable to both the department and the provider; and
    9. (9) not offer membership nor accept members into the program who are Medicaid clients.

12. (l) Responsibilities of the EMS provider. During the license period the provider's responsibilities shall include:

    1. (1) assuring that all response-ready and in-service vehicles are maintained, operated, equipped and staffed in accordance with the requirements of the provider's license;
    2. (2) monitoring and taking appropriate action regarding the quality of patient care provided by the service;
    3. (3) monitoring and taking appropriate action regarding the performance of all personnel involved in the provision of EMS; and ensuring that all personnel are properly certified or licensed;
    4. (4) assuring that continuing education (CE) training is current in accordance with the requirements in §157.38 of this title (regarding Continuing Education);
    5. (5) assuring that all personnel, when on an in-service vehicle or when on-scene, are prominently identified by name, certification or license level and provider name;
    6. (6) maintaining confidentiality of patient information;
    7. (7) assuring that all relevant patient care information is supplied to receiving facilities upon delivery of patients;
    8. (8) assuring that all requested patient records are made promptly available to the medical director;
    9. (9) making available on each vehicle current protocols, current equipment and supply lists, a copy of the provider license and the correct designation;
    10. (10) monitoring and enforcing general safety policies including at least personal protective equipment, immunizations and communicable disease exposure and emergency vehicle operation;
    11. (11) assuring ongoing compliance with the terms of first responder agreements;
    12. (12) assuring that all documents, reports or information provided to the department are current, truthful and correct;
    13. (13) maintaining compliance with all applicable laws and regulations;
    14. (14) submission of run response data upon request by department approved method; and

    15. (15) notification of the department within 10 days if:

        1. (A) a vehicle is substituted or replaced;
        2. (B) a vehicle is added, with submission of the nonrefundable fee if applicable; and/or

        3. (C) there is a change in the:

           1. (i) number of any designation level in the fleet;
           2. (ii) official business address;
           3. (iii) service director;
           4. (iv) medical director, with submission of the new agreement; and/or
           5. (v) physical sublocation or station address.

13. (m) License renewal process.

    1. (1) The department shall notify the EMS provider at least 90 days before the expiration date of the current license at the address shown in the current records of the department. It is the responsibility of the provider to notify the department of any change of address. If a notice of expiration is not received, it is the responsibility of the provider to notify the department and request license renewal application information.
    2. (2) Providers shall submit a completed application and nonrefundable fee, if applicable, and must verify continuing compliance with the requirements of their license.
    3. (3) If a provider has not met all requirements for a provider license, the provider may apply for a provisional license by submitting a request and, in addition to the regular nonrefundable licensure fee if applicable, a nonrefundable fee of $30. One provisional license, valid for not more than 60 days, may be granted only to prevent probable adverse impact to the health and safety of the service community. Without a provisional license, a provider may not operate if there is a lapse in time between license expiration and license renewal.
14. (n) Advertisements. If there are more than five paid staff, but the organization is composed of at least 75% volunteer personnel, the provider shall pay a nonrefundable fee but may continue to advertise the service as volunteer. A provider shall not advertise levels of designation or types of patient care which cannot be provided. Displays on vehicles which indicate the provider's name or the appropriate designation level of the vehicles shall not be considered advertising.
15. (o) Surveys. All initial candidates for a provider license shall be required to have a comprehensive survey by the department prior to the license being granted. Surveys may be conducted for cause on any licensed provider.
16. (p) Unannounced inspections. Randomly and/or in response to complaints, the department may conduct unannounced inspections to insure compliance of the provider license holder. Inspections may be conducted at any time, including nights or weekends. The department may review all components of provider licensure during an unannounced inspection. Violations or deficiencies may result in disciplinary action as authorized by §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation or Denial of a Provider License). The department may grant a reasonable period of time for the provider to correct deficiencies. If the department must reinspect the provider because of noncompliance noted during a previous inspection, the provider shall pay a nonrefundable fee of $30, if applicable.
17. (q) Failure to correct identified deficiencies. Failure to correct identified deficiencies within a period of time determined to be reasonable by the department or if the deficiencies are found to be repeated, the provider shall be subject to disciplinary actions in accordance with §157.16 of this title.
18. (r) For all applications and renewal applications, the department (or the board) is authorized to collect subscription and convenience fees, in amounts determined by the Texas Online Authority, to recover costs associated with application and renewal application processing through Texas Online.

Source Note:The provisions of this §157.11 adopted to be effective September 1, 2000, 25 TexReg 3749; amended to be effective June 1, 2004, 29 TexReg 4492.