Ariz. Admin. Code § 9-25-908

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-25-908 - Operations (Authorized by A.R.S. Sections 36-2204.02, 36-2211, 36-2224, 36-2232, 36-2233, 36-2237, 36-2241)

A. Insurance: A certificate holder shall:

1. Either:

a. Maintain with an insurance company authorized to transact business in this state:

i. A minimum single occurrence automobile liability insurance coverage of $1,000,000 for ground ambulance vehicles;

ii. A minimum single occurrence professional liability insurance coverage for the ground ambulance service of $1,000,000; and

iii. If the certificate holder provides ALS services or critical care services, a minimum single occurrence professional liability insurance coverage for personnel of the ground ambulance service providing ALS services or critical care services of $1,000,000; or

b. Be self-insured for the amounts in subsection (A)(1)(a); and

2. Submit to the Department within seven days after renewal of the insurance coverage in subsection (A)(1)(a) or a change in how the insurance coverage in subsection (A)(1)(a) or (b) is obtained:

a. A copy of the certificate of insurance in subsection (A)(1)(a); or

b. Documentation of self-insurance according to subsection (A)(1)(b).

B. Record Retention: According to A.R.S. § 36-2241, a certificate holder shall maintain the following records for the Department's review and inspection:

1. The certificate holder's financial statements;

2. All federal and state income tax records;

3. All employee-related expense reports and payroll records;

4. All bank statements and documents used to reconcile accounts;

5. All documents establishing the depreciation of assets, such as schedules or accounting records on ground ambulance vehicles, equipment, office furniture, and other plant and equipment assets subject to depreciation;

6. All prehospital history incident reports, as specified in subsection (J)(1);

7. All patient billing and reimbursement records;

8. All dispatch records, as specified in subsection (J)(2);

9. All policies and procedures required by this Article or Article 2, 10, or 11 of this Chapter;

10. All plans required by this Article or Article 2, 10, or 11 of this Chapter;

11. Documentation of the analysis of response time performance according to subsection (G)(2);

12. Documentation of the analysis of performance of interfacility transports of patients with no time-critical condition, including patients with a time-sensitive condition, according to subsection (H)(1);

13. Documentation of notification to the Department of instances of noncompliance according to subsection (K)(1)(c);

14. All back-up agreements, contracts, grants, and financial assistance records related to ground ambulance vehicles, ambulance response, and transport;

15. All written complaints about the ground ambulance service; and

16. Information about destroyed or otherwise irretrievable records in a file including:

a. A list of each record destroyed or otherwise irretrievable,

b. A description of the circumstances under which each record became destroyed or otherwise irretrievable, and

c. The date each record was destroyed or became otherwise irretrievable.

C. Staffing: A certificate holder shall ensure that:

1. If a ground ambulance vehicle is marked with a level of service, the ground ambulance vehicle is staffed to provide the level of service identified;

2. An administrative medical director for the ground ambulance service complies with requirements in R9-25-201(F) and R9-25-502(B);

3. Policies and procedures are established, implemented, and maintained that cover:

a. Job descriptions, duties, and qualifications, including required skills and knowledge for EMCTs and other employees; and

b. Orientation and in-service education for EMCTs and other employees;

4. An EMCT employed by the ground ambulance service:

a. Is assigned patient care duties consistent with the EMCT's scope of practice and the administrative medical director's evaluation of the EMCT's skills and capabilities;

b. Complies with the protocols required in R9-25-201(E)(2);

c. Receives training on the policies and procedures required in R9-25-201(E)(3)(b); and

d. Receives ongoing education, training, or remediation consistent with the policies and procedures required in R9-25-201(E)(3)(b)(x); and

5. Staffing of ground ambulance vehicles:

a. For the provision of BLS or ALS, is consistent with A.R.S. § 36-2239; and

b. Effective January 1, 2025, for critical care services, includes at least one:

i. Paramedic with an additional endorsement, indicating additional training and authorization from the Department to provide critical care services; or

ii. Registered nurse.

D. Communications and Advertising: A certificate holder shall ensure that the ground ambulance service:

1. Makes a good faith effort to communicate information:

a. About its hours of operation to the general public through print media, broadcast media, the Internet, or other means; and

b. About resource availability and deployment to other EMS providers in overlapping and surrounding service areas;

2. Does not advertise that the ground ambulance service:

a. Provides a type of service or level of service other than what is granted in the certificate of necessity,

b. Operates in the service area other than what is granted in the certificate of necessity, or

c. In a manner that circumvents the use of 9-1-1 or another similarly designated emergency telephone number;

3. Establishes, implements, and maintains the protocol for providing information to emergency receiving facility staff concurrent with the transfer of care, required in R9-25-201(E)(2)(d)(i), which includes:

a. The date and time the dispatch was received by the ground ambulance service;

b. The unique number used by the ground ambulance service to identify the run;

c. The name of the ground ambulance service;

d. The number or other identifier of the ground ambulance vehicle used for the run;

e. The following information about the patient:

i. The patient's name;

ii. The patient's date of birth or age, as available;

iii. The principal reason for requesting services for the patient;

iv. The patient's medical history, including any chronic medical illnesses, known allergies to medications, and medications currently being taken by the patient;

v. The patient's level of consciousness at initial contact and when reassessed;

vi. The patient's pulse rate, respiratory rate, oxygen saturation, and systolic blood pressure at initial contact and when reassessed;

vii. The results of an electrocardiograph, if available;

viii. The patient's glucose level at initial contact and when reassessed, if applicable;

ix. The patient's level of responsiveness score, as applicable, at initial contact and when reassessed;

x. The results of the patient's neurological assessment, if applicable; and

xi. The patient's pain level at initial contact and when reassessed; and

f. Any procedures or other treatment provided to the patient at the scene or during transport, including any agents administered to the patient; and

4. Establishes, implements, and maintains a protocol for providing information to another certificate holder, ambulance service, EMS provider, or health care institution concurrent with the transfer of care, which includes the information in subsections (D)(3)(c), (d), (e), and (f).

E. Dispatch and Scheduling: A certificate holder shall ensure that:

1. A contract or other agreement, including internal policies and procedures, to provide dispatch exists and includes:

a. Information about other certificate holders with which the certificate holder has a back-up agreement;

b. The process and parameters under which a ground ambulance vehicle of another certificate holder will be dispatched to respond to a call to which a ground ambulance vehicle of the certificate holder cannot respond;

c. Except as specified in subsection (E)(2), for an area within the certificate holder's service area that overlaps with another certificate holder's service area, that the nearest ground ambulance vehicle to the patient's location, under either certificate holder that can provide the necessary level of service, will be directed to respond to a call made through 9-1-1 or a similar dispatch system; and

d. If the entity providing dispatch is external to the ground ambulance service, a requirement that the certificate holder receive a copy of each dispatch made under the contract or other agreement;

2. If a certificate holder has a ground ambulance service contract under R9-25-1104 with a political subdivision, the ground ambulance service contract contains requirements that specify a method for dispatch, which may differ from requirements in subsection (E)(1)(c); and

3. For an interfacility transport of a patient with no time-critical condition:

a. Unless already specified in a written agreement between the certificate holder and the person requesting the interfacility transport, the entity receiving the request for the interfacility transport provides an estimated time of arrival to the person requesting the interfacility transport at the time that the interfacility transport is requested;

b. If the estimated time of arrival provided according to subsection (E)(3)(a) changes to a later time, the ground ambulance service, either directly or indirectly, does one of the following:

i. Contacts another ground ambulance service to respond to the dispatch, based on the ground ambulance service's backup plan and back-up agreements;

ii. Provides to the contact at the requesting health care institution the name and telephone number of another ground ambulance service with which the ground ambulance service has a back-up agreement; or

iii. Provides an amended estimated time of arrival to the person requesting transport that takes into consideration:

(1) The patient's condition and needs, and

(2) Health and safety;

c. Effective January 1, 2025, unless otherwise specified on the certificate holder's certificate of necessity, the actual time of arrival of a ground ambulance vehicle at a health care institution for an interfacility transport of a patient who does not have a time-critical condition is within 60 minutes of the estimated time of arrival in subsection (E)(3)(a) or amended estimated time of arrival in subsection (E)(3)(b)(iii) for at least 90% of the interfacility transports; and

d. If the interfacility transport does not meet the standards in subsection (E)(3)(c), factors that may have contributed to not meeting the standards are considered through the quality improvement process in subsection (K)(2)(b).

F. Transport: A certificate holder:

1. Shall only provide ambulance response or transport within the service area identified in the certificate holder's certificate of necessity except:

a. When authorized by a service area's dispatch, before the service area's ground ambulance vehicle arrives at the scene;

b. According to a back-up agreement; or

c. If the area is not included in the service area of another certificate holder;

2. Except as specified in subsection (F)(3), shall transport a patient in the certificate holder's service area who requests transport; and

3. May deny transport to a patient in the certificate holder's service area:

a. As limited by A.R.S. § 36-2224;

b. If the patient is in a health care institution and the patient's medical condition requires a level of care or monitoring during transport that exceeds the scope of practice of the ambulance attendants' certification;

c. If the transport may result in an immediate threat to the ambulance attendant's safety, as determined by the ambulance attendant, the certificate holder, the administrative medical director, or a physician providing on-line medical direction and does not affect the ground ambulance service's hours of operation;

d. If the patient is 18 years or age or older, or meets the requirements in A.R.S. § 12-2451, 44-131, or 44-132, and refuses to be transported; or

e. If the patient is in a health care institution and does not meet the federal requirements for medically necessary ground vehicle ambulance transport as identified in 42 CFR 410.40.

G. Response Time Performance: A certificate holder shall ensure that:

1. Response times resulting from a 9-1-1 or similar system dispatch or, if applicable, a request for the interfacility transport of a patient with a time-critical condition comply with requirements of the certificate holder's certificate of necessity;

2. Response time performance, based on the information is subsection (J)(2), is assessed at least every six months for compliance with requirements of the certificate holder's certificate of necessity;

3. The following are reported to the Department annually, in a Department-provided format, concurrent with the submission of the information required in R9-25-909:

a. Response time data that complies with requirements in A.R.S. § 36-2232(A)(3), and

b. The results of the response time performance assessments in subsection (G)(2); and

4. If response time performance does not comply with requirements of the certificate holder's certificate of necessity, either:

a. A corrective action plan, developed according to R9-25-910(E)(2)(a) through (d), is submitted to the Department with the information required in subsection (G)(3); or

b. The certificate holder submits to the Department with the information required in subsection (G)(3) documentation demonstrating that noncompliance was due to:

i. A situation specified in A.R.S. § 36-2232(G), or

ii. An external factor beyond the control of the certificate holder.

H. Performance of Interfacility Transports of Patients with No Time-Critical Condition: Effective January 1, 2025, a certificate holder shall ensure that:

1. The performance of interfacility transports of patients with no time-critical condition, including patients with a time-sensitive condition:

a. Is based on the information in subsection (J)(2);

b. Is assessed at least every six months;

c. Includes the analysis of:

i. The number of calls received;

ii. The time a call was received;

iii. The estimated time of arrival;

iv. The time of arrival at the patient's location; and

v. Any other information about cancelled calls, amended estimated times of arrival, or delays that may have factored into performance; and

d. Includes a description of any actions taken by the certificate holder to improve performance;

2. The results of the performance assessments in subsection (H)(1) are reported to the Department annually in a Department-provided format, concurrent with the submission of the information required in R9-25-909; and

3. If the performance of interfacility transports of patients with no time-critical condition does not comply with subsection (E)(3)(c) or requirements of the certificate holder's certificate of necessity, as applicable, either:

a. A corrective action plan, developed according to R9-25-910(E)(2)(a) through (d), is submitted to the Department with the information required in subsection (H)(2); or

b. The certificate holder submits to the Department with the information required in subsection (H)(2) documentation demonstrating that noncompliance was due to an external factor beyond the control of the certificate holder.

I. The Department may require that a certificate holder contract for third-party monitoring of response time performance as part of a:

1. Political subdivision contract, unless both parties to the contract waive the requirement; or

2. Corrective action plan.

J. Records: A certificate holder shall ensure that:

1. A prehospital incident history report, in a Department-provided format, is created for each patient that includes the following information, as available:

a. The name and identification number of the ground ambulance service;

b. Information about the software for the storage and submission of the prehospital incident history report;

c. The unique number assigned to the run;

d. The unique number assigned to the patient;

e. Information about the response to the dispatch, including:

i. The level of service requested;

ii. Information obtained by the person providing dispatch about the request;

iii. Information about the ground ambulance vehicle assigned to the dispatch;

iv. Information about the EMCTs responding to the dispatch;

v. The priority assigned to the dispatch; and

vi. Response delays, as applicable;

f. The date and time that:

i. The call requesting service was received through the 9-1-1 or similar dispatch system,

ii. The request was received by the person providing dispatch,

iii. The ground ambulance service received the dispatch,

iv. The ground ambulance vehicle left for the patient's location,

v. The ground ambulance vehicle arrived at the patient's location,

vi. The EMCTs in the ground ambulance vehicle arrived at the patient's side,

vii. Transfer of care for the patient occurred at a location other than the destination,

viii. The ground ambulance vehicle departed the patient's location,

ix. The ground ambulance vehicle arrived at the destination,

x. Transfer of care for the patient occurred at the destination, and

xi. The ground ambulance vehicle was available to take another call;

g. Information about the patient, including:

i. The patient's first and last name;

ii. The address of the patient's residence;

iii. The county of the patient's residence;

iv. The country of the patient's residence;

v. The patient's gender, race, ethnicity, and age;

vi. The patient's estimated weight;

vii. The patient's date of birth; and

viii. If the patient has an alternate residence, the address of the alternate residence;

h. The primary method of payment for services and anticipated level of payment;

i. Information about the scene, including:

i. Specific information about the location of the scene;

ii. Whether the ground ambulance vehicle was first on the scene;

iii. The number of patients at the scene;

iv. Whether the scene was the location of a mass casualty incident; and

v. If the scene was the location of a mass casualty incident, triage information;

j. Information about the reason for requesting service for the patient, including:

i. The date and time of onset of symptoms and when the patient was last well;

ii. Information about the principal reason the patient needs services;

iii. The patient's symptoms;

iv. The results of the EMCT's initial assessment of the patient;

v. If the patient was injured, information about the injury and the cause of the injury;

vi. If the patient experienced a cardiac arrest, information about the etiology of the cardiac arrest and subsequent treatment provided; and

vii. For an interfacility transport, the reason for the transport;

k. Information about any specific barriers to providing care to the patient;

l. Information about the patient's medical history, including;

i. Known allergies to medications,

ii. Surgical history,

iii. Current medications, and

iv. Alcohol or drug use;

m. Information about the patient's current medical condition, including the information in subsections (D)(2)(e)(v) through (xi) and the time and method of assessment;

n. Information about agents administered to the patient, including the dose and route of administration, time of administration, and the patient's response to the agent;

o. If not specifically included under subsection (J)(1)(l), (l)(iv), (m), or (n), the information required in A.A.C. R9-4-602(A);

p. Information about any procedures performed on the patient and the patient's response to the procedure;

q. Whether the patient was transported and, if so, information about the transport;

r. Information about the destination of the transport, including the reason for choosing the destination;

s. Whether transfer of care for the patient to another EMS provider or ambulance service occurred and, if so, identification of the EMS provider or ambulance service;

t. Unless transfer of care for the patient to another EMS provider or ambulance service occurred, information about:

i. Whether the destination facility was notified that the patient being transported has a time-critical condition and the time of notification,

ii. The disposition of the patient at the destination, and

iii. The disposition of the run;

u. Any other narrative information about the patient, care receive by the patient, or transport; and

v. The name and certification level of the EMCT providing the information; and

2. Dispatch records for each call or request for service, including all cancelled runs, contain the following information, in a Department-provided format:

a. The name of the ground ambulance service;

b. The date;

c. Level of service;

d. Type of service;

e. Staffing of the run;

f. Time of receipt of the call;

g. Time of the dispatch;

h. The estimated time of arrival, as provided according to subsection (E)(3)(a) if applicable;

i. Departure time to the patient's location;

j. Address of the patient's location;

k. Time of arrival at the patient's location;

l. Departure time to the destination health care institution;

m. Name and address of the destination health care institution;

n. Time of arrival at the destination health care institution;

o. Any type of delay, if applicable;

p. The unique reference number used by the ground ambulance service to identify the patient, dispatch, or run;

q. The number assigned to the ground ambulance vehicle by the certificate holder;

r. The priority assigned by a certificate holder to the response;

s. The scene locality; and

t. Whether the dispatch is a scheduled transport.

K. Assuring Consistent, Compliant Performance: A certificate holder shall:

1. Adopt, implement, and maintain policies and procedures for:

a. Complaint resolution;

b. Assessing the ground ambulance service's compliance with requirements in this Article, Articles 2, 10, or 11 of this Chapter, or A.R.S. Title 36, Chapter 21.1, including the review of:

i. The information provided to an emergency receiving facility for compliance with the protocol required in R9-25-201(E)(2)(d),

ii. Chain of custody for drugs,

iii. Compliance with minimum equipment requirements for a ground ambulance vehicle,

iv. Compliance with requirements in R9-25-201(E)(3), and

v. The quality improvement parameters in subsection (K)(2)(b) related to the provision of services;

c. Notifying the Department within 30 calendar days after completing an assessment in subsection (K)(1)(b), during which an instance of noncompliance was identified, and submitting a corrective action plan that complies with requirements in R9-25-910(E)(2)(a) through (d); and

d. A quality improvement process according to subsection (K)(2);

2. Establish, document, and implement a quality improvement process, as specified in policies and procedures, through which:

a. Data related to initial patient assessment, patient care, transport services provided, and patient status upon arrival at the destination are:

i. Collected continuously;

ii. For the information required in subsection (J)(1), submitted to the Department, in a format specified by the Department and within 48 hours after the beginning of a run, for quality improvement purposes; and

iii. If notified that the submission of information to the Department according to subsection (K)(2)(a)(ii) was unsuccessful, corrected and resubmitted within seven days after notification;

b. Continuous quality improvement processes are developed and implemented to identify, document, and evaluate issues related to the provision of services to ensure quality patient care, including:

i. Care provided to patients with time-critical conditions, including deviations from national treatment standards for a patient with a time-critical condition;

ii. Transport, including an interfacility transport of a patient that does not have a time-critical condition;

iii. Documentation; and

iv. Patient status upon arrival at the destination;

c. A committee consisting of the administrative medical director, the individual managing the ground ambulance service or designee, and other employees as appropriate:

i. Review the data in subsection (K)(2)(a) and any issues identified in subsection (K)(2)(b) on at least a quarterly basis; and

ii. Implement activities to improve performance when deviations in patient care, transport, or documentation are identified; and

d. The activities in subsection (K)(2)(c) are documented, consistent with A.R.S. §§ 36-2401, 36-2402, and 36-2403; and

3. Ensure that the information required in subsection (J)(2) is submitted to the Department, in a Department-provided format, and within 48 hours after the receipt of a call or request for service.

L. If a certificate holder has a reasonable basis to believe that a situation or circumstance specified according to A.R.S. § 36-2211(A) has occurred, the certificate holder shall:

1. If applicable, take immediate action to prevent the recurrence of the situation or circumstance;

2. Report the suspected situation or circumstance to the Department and, if applicable, according to A.R.S. § 13-3620 or 46-454;

3. Document:

a. The suspected situation or circumstance;

b. Any action taken according to subsection (L)(1); and

c. The report in subsection (L)(2);

4. Maintain the documentation in subsection (L)(3) for at least 12 months after the date of the report in subsection (L)(2);

5. Initiate an investigation of the situation or circumstance and document the following information within five working days after the report required in subsection (L)(2):

a. The dates, times, and description of the situation or circumstance;

b. A description of any injury to a patient related to the suspected situation or circumstance and any change to the patient's physical, cognitive, functional, or emotional condition;

c. The names of witnesses to the suspected situation or circumstance; and

d. The actions taken by the certificate holder to prevent the suspected situation or circumstance from occurring in the future; and

6. Maintain a copy of the documented information required in subsection (L)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

M. A certificate holder shall notify the Department of a change in the number or location of suboperation stations in the certificate holder's service area, according to A.R.S. § 36-2232(C)(4), and include:

1. The certificate of necessity number for the ground ambulance service;

2. The name of the ground ambulance services on the certificate of necessity;

3. The name, title, address, e-mail address, and telephone number of an individual whom the Department may contact about the notification; and

4. Information about the change, including, as applicable:

a. How the number of suboperation stations is changed from the information on the certificate holder's certificate of necessity;

b. The address of each suboperation station that is being removed from service; and

c. The address, hours of operation, and telephone number of each new suboperation station located within the service area.

N. A certificate holder shall submit to the Department, no later than 180 days after the certificate holder's fiscal year end, the information in the Ambulance Revenue and Cost Report specified in R9-25-909(A) or (C), as appropriate to the certificate holder's business organization.

Ariz. Admin. Code § R9-25-908

New Section adopted by final rulemaking at 7 A.A.R. 1098, effective February 13, 2001 (Supp. 01-1). New Section made by final rulemaking at 30 A.A.R. 581, effective 3/7/2024.