Tenn. Comp. R. & Regs. 1200-12-01-.14 - EMERGENCY MEDICAL SERVICES STANDARDS AND CATEGORIES FOR LICENSED AMBULANCE SERVICE AND MOBILE PREHOSPITAL EMERGENCY CARE

The following rules are promulgated to establish minimum standards and categorical capabilities for emergency medical services and/or ambulance services licensed in Tennessee and to govern emergency medical services provided to a patient.

(1) Definitions.

(a) "Advanced Life Support" means advanced emergency medical technicians, or other EMS personnel having a higher level of licensure, who treat life-threatening or aggravating medical emergencies under medical control.

(b) "Basic Life Support" means EMS personnel, authorized through the appropriate level of licensure, who treat life-threatening medical emergencies under medical control.

(c) "Base of Operations" means the principal location and physical structure (i.e. building), having a street address, city and zip code, from which ambulances and/or personnel operate to provide ambulance service within a service area.

(d) "Division" means the Division of Emergency Medical Services of the Tennessee Department of Health.

(e) "Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that it could put the patient's health in serious jeopardy, cause serious impairment to bodily function, or cause serious dysfunction of any body organ, system or part without immediate medical attention.

(f) "Emergency Run" means a transport or response, occurring or accomplished without delay, to the perceived need for care for an emergent, trauma or medical condition in order to prevent loss of life or aggravation of illness or injury, including but not limited to the following:

1. Cardiac arrest;

2. Difficulty breathing/shortness of breath/airway impairment;

3. Severe chest pain or heart attack;

4. Severe motor vehicle crashes/entrapment or pin-in;

5. Decreases in level of consciousness/diabetic emergencies;

6. Heat emergencies;

7. Severe lacerations or possible amputations; severe burns (thermal, chemical or electrical);

8. Possible stroke; and

9. Complications of childbirth.

(g) "Emergency Medical Service Director" ("Service Director") means an individual who directs the planning, development, implementation, coordination, administration, monitoring and evaluation of services provided by a licensed ambulance service.

(h) "Emergency Medical Service Medical Director" ("Medical Director") means an individual who has an active, unencumbered license to engage in the practice of medicine pursuant to title 63, chapter 6, or chapter 9, and who provides medical advice, direction, oversight, quality assurance and authorization to emergency medical services personnel at a licensed ambulance service, and/or emergency medical services educational institution.

(i) "Medical Control" means the instruction, advice or orders given by a physician in accordance with locally or regionally approved practices.

(j) "Minimum Standards" means the minimum requirements for ambulance and emergency medical services established by law, regulation, and prevailing standards of care.

(k) "Service Area" means the political and geographical area with a population that can be expected to use the services offered by a specific provider.

(l) "Specialty Care Transport" ("SCT") means the inter-facility transportation of a critically injured or ill patient by a ground ambulance vehicle, including the provision of medically necessary supplies and services, which requires a level of service beyond the scope of a paramedic.

(m) "Substation" means the physical structure from which ambulances and personnel operate on a day-to-day basis to provide ambulance services, which are supplementary to the services provided from the base of operations for the specified city or county.

(n) "Volunteer ambulance service" means a not-for-profit service that uses volunteer personnel and restricts emergency operations to scheduled events or serves as a relief organization under the constraint of the main or governmental emergency medical services provider within a service area.

(2) Ambulance Operations.

(a) Each base of operations must hold a State-issued service license for the county in which it is located.

(b) No ambulance service shall position, post, stage or otherwise offer or make an ambulance available within the service area where the county, municipality or special purpose district or authority has current ordinances or resolutions preventing such without prior authorization of the governing body of the service area.

(c) Notwithstanding any other provision, nothing shall preclude an ambulance provider with federal contracts from providing service as required under those contracts.

(3) Classification of Services.

(a) Each ambulance service license the Division issues must indicate the minimum clinical level of service that the ambulance service can provide.

(b) The Division shall grant an ambulance service license only after it verifies that the service is in compliance with Division rules for immediate or scheduled patient transport.

(c) The Division recognizes the following classes of service for licensing or authorization of ambulances and/or emergency medical services:

1. Category A: Primary emergency provider. Each ambulance service the local government designates as the primary provider by recognizing it as such or contracting with it to provide initial response to scene emergencies shall operate advanced and/or basic life support ambulances within the service area 24 hours a day. The service may also provide ambulance transport services under its license for its county specific service area. It shall coordinate licensed volunteer ambulance services as well as coordinate and oversee emergency medical response agencies within its jurisdiction.

(i) Level 1: 100% of Emergency runs shall be made with an Advanced Life Support-equipped ambulance and staffed with a paramedic and a minimum of an EMT.

(ii) Level 2: 90% of Emergency runs shall be made with an Advanced Life Support-equipped ambulance and staffed with a paramedic and a minimum of an EMT.

(iii) Level 3: 100% of Emergency runs shall be made with a Basic Life Support-equipped ambulance and staffed with two AEMTs.

(iv) Level 4: 90% of Emergency runs shall be made with a Basic Life Support-equipped ambulance and staffed with an AEMT and an EMT.

2. Category B: Licensed Ambulance Transport Services. Each licensed ambulance service shall operate ambulances for unscheduled or scheduled transportation of patients. The level of the licensed ambulance service must be consistent with their issued service license level.

(i) Level 1: 100% of transports shall be made with an Advanced Life Support-equipped ambulance and staffed with a paramedic and a minimum of an EMT.

(I) Notwithstanding any other requirements under this section, Level 1 transports may be conducted by an Advanced Life Support-equipped ambulance with a paramedic serving as the sole medical staff, provided there is also an ambulance operator who satisfies the ambulance driver requirements of Tenn. Comp. R. & Reg. 1200-1201-.10, possesses current CPR certification, has completed a defensive driving course, and has demonstrated competency.

(II) Medical Directors of ambulance services utilizing paramedic-only Level 1 transports shall notify the Office of EMS of their intent to utilize EMS-As or EMRs.

(ii) Level 2: 90% of transports shall be made with an Advanced Life Support-equipped ambulance and staffed with a paramedic and a minimum of an EMT.

(I) Notwithstanding any other requirements under this section, Level 2 transports may be conducted by an Advanced Life Support-equipped ambulance with a paramedic serving as the sole medical staff, provided there is also an ambulance operator who satisfies the ambulance driver requirements of Tenn. Comp. R. & Reg. 1200-1201-.10, possesses current CPR certification, has completed a defensive driving course, and has demonstrated competency.

(II) Medical Directors of ambulance services utilizing paramedic-only Level 2 transports shall notify the Office of EMS of their intent to utilize EMS-As or EMRs.

(iii) Level 3: 100% of transports shall be made with a Basic Life Support-equipped ambulance and staffed with two AEMTs 100% of time.

(I) Notwithstanding any other requirements under this section, Level 3 transports may be conducted by a Basic Life Support-equipped ambulance with an Emergency Medical Technician-Basic or Emergency Medical Technician-Advanced serving as the sole medical staff for Basic Life Support ambulances, provided there is also an ambulance operator who satisfies the ambulance driver requirements of Tenn. Comp. R. & Reg. 1200-12-01-.10, possesses current CPR certification, has completed a defensive driving course, and has demonstrated competency.

(II) Medical Directors of ambulance services utilizing EMT Basic or Advanced Level 3 transports shall notify the Office of EMS of their intent to utilize EMS-As or EMRs.

(iv) Level 4: 90% of transports shall be made with a Basic Life Support-equipped ambulance and staffed with a minimum of two EMTs.

(I) Notwithstanding any other requirements under this section, Level 4 transports may be conducted by a Basic Life Support-equipped ambulance with an Emergency Medical Technician-Basic or Emergency Medical Technician-Advanced serving as the sole medical staff for Basic Life Support ambulances, provided there is also an ambulance operator who satisfies the ambulance driver requirements of Tenn. Comp. R. & Reg. 1200-12-01-.10, possesses current CPR certification, has completed a defensive driving course, and has demonstrated competency.

(II) Medical Directors of ambulance services utilizing EMT Basic or Advanced Level 4 transports shall notify the Office of EMS of their intent to utilize EMS-As or EMRs.

(v) Services conducting paramedic-only Level 1 or Level 2 transports are responsible for ensuring that each ambulance operator is properly trained and has demonstrated competency in safely lifting and moving patients via ambulance cot. Operators are forbidden from providing direct patient care that requires licensure as healthcare providers by the Tennessee Department of Health, as these operators lack such licensure. All other statutes and rules regarding patient transport services remain in full force and effect.

(vi) Services conducting EMT Basic or Advanced-only Level 3 or Level 4 transports are responsible for ensuring that each ambulance operator is properly trained and has demonstrated competency in safely lifting and moving patients via ambulance cot. Operators are forbidden from providing direct patient care that requires licensure as healthcare providers by the Tennessee Department of Health, as these operators lack such licensure. All other statutes and rules regarding patient transport services remain in full force and effect.

(vii) Services must require all operators hired under this part to attain, at minimum, licensure as an EMT-Basic within twelve (12) months from the operator's original hire date.

(viii) Services are prohibited from employing, as an operator, any individual previously employed in the state of Tennessee under this part, who has failed to attain or will be unable to attain licensure as an EMT-Basic or higher, within twelve (12) months of that individual's original hire date.

3. Category C: Volunteer not-for-profit ambulance services using volunteer personnel shall restrict emergency operations to scheduled events or serve as a relief organization under the coordination of the primary emergency provider. Volunteer ambulance services may, in times of disaster, be used in their communities as deemed necessary by local authorities and/or primary service providers. All Category C services shall be Category B, Level 4 transport services at a minimum.

(d) Conditional Ambulance Services. The Division may place a new service or a service having deficiencies in a conditional license category for up to ninety (90) days from the date of the deficiency or issuance of the license. Placing the license in a conditional license category is not disciplinary action.

(4) Personnel. Each ambulance or emergency medical service shall assign qualified persons to perform functions to ensure compliance with its licensure as follows:

Each ambulance service shall retain an Emergency Medical Services Medical Director ("Medical Director") who serves as medical authority for the ambulance service and functions as a liaison to the medical community, medical facilities, and governmental entities. His or her duties shall include, but not be limited to, the following:

(a) Quality management and improvement of patient care, including the following:

1. Development of protocols, standing orders, training, procedures, approval of medications and techniques permitted for field use by service personnel in accordance with regulations of the Division;

2. Quality management and improvement of field performance as may be achieved by direct observation, field instruction, in-service training or other means including, but not limited to:

(i) Ambulance run report review;

(ii) Review of field communications tapes;

(iii) Post-run interviews and case conferences;

(iv) Critiques of simulated or actual patient presentations; and

(v) Investigation of complaints or incidents reports.

(b) The medical director shall have disciplinary and/or corrective action authority sufficient to oversee quality management and improvement of patient care as the service director of the ambulance service deems appropriate.

(5) Each ambulance service shall require and document continuing education of at least fifteen (15) contact hours annually for ninety-five percent (95%) of emergency care personnel. Each service shall implement a competency-based evaluation program in accordance with Board policy.

(6) Each ambulance service shall also conduct training for new procedures or remedial instruction as ordered by the medical director and or emergency medical service director.

(7) EMS/Ambulance Services who do not use educational institutions or other educational accrediting bodies to provide continuing education contact hour credit for in-service training hours for renewal of personnel licenses may count such in-service training hours as continuing education contact hours as required for renewal of personnel licenses, provided the service meets the following requirements:

(a) The service must have an individual who maintains, at a minimum, an authorization of an EMT instructor/coordinator authorized by the Division of EMS to maintain educational records and coordinate in-service education for the service's personnel.

(b) The service must maintain all educational records for five (5) years.

(c) The service's educational records must contain:

1. A curriculum vitae establishing the instructor's expertise in the content for each lesson plan;

2. Lesson plans shall include, but not be limited to:

(i) A list of course objectives, and

(ii) A course outline;

3. Course evaluations by students;

4. An evaluation of each student's performance in the course; and

5. A sign-in sheet bearing the signatures of all students who attended the course.

(d) The service's training records will be randomly audited annually for compliance.

(8) Service permits issued by the Division shall be specific to the county in which the service has its base of operations. The service owner may maintain records for such operations at a central location. The service owner shall maintain records to detail all activities at the county base of operations.

(9) Licensing Procedures.

(a) No person, partnership, association, corporation, or state, county or local government unit, or division, department, board or agency thereof, shall establish, conduct, operate, or maintain as a business in the state of Tennessee any ambulance, invalid vehicle service or vehicle operated with a patient cot for transport of persons without having a license.

1. A license shall only be issued to the applicant named and only for the base of operations and substations listed in the application for licensure.

2. Licenses are not transferable or assignable and shall expire annually on June 30.

3. The license shall be conspicuously posted at the base of operations.

(b) Initial Licensure.

1. In order to make application for a new license, applicants shall have service names that are unique and the business name shall be registered with the Department of State, Division of Business Services.

2. The applicant shall submit an application on a form prepared by the Division. The service shall report the names, titles and summary of responsibilities of the service director and those persons who will be supervising the ambulance service as officers, directors or other ambulance service officials, and information as to any misdemeanor or felony convictions, or disciplinary sanctions against licenses, certifications, or other authorizations to practice a health care occupation or profession, that have been imposed against them in this or any other state.

3. Each applicant for a license shall pay the annual license fee and permit fees based on the number of ambulances or permitted invalid vehicles. The fees must be submitted with the application and are non-refundable.

4. The issuance of an application form is in no way a guarantee that the completed application will be accepted or that a license will be issued by the Division. Patients shall not be transported until a license has been issued. Applicants shall not hold themselves out to the public as being an ambulance service until the license has been issued. A license shall not be issued until the service is in substantial compliance with these rules and regulations, including submission of all information required by T.C.A. § 68-140-306, or as later amended, and of all information required by the Division.

5. The applicant shall not use subterfuge or other evasive means to obtain a license, such as filing for a license through a second party when an individual has been denied a license, had a license disciplined, or has attempted to avoid the inspection and review process in this or any other state.

6. An applicant shall allow the premises, the service, and its vehicles to be inspected by a representative of the Division.

7. In the event that deficiencies are noted, the applicant shall submit a plan of corrective action to the Division. Once the deficiencies have been corrected, then the Division shall reconsider the application for licensure. If vehicles have failed inspection, a repeat inspection fee must be submitted to the Division.

(c) License Renewal.

1. In order to renew a license, each service shall subject its premises, operational procedures, records, equipment, personnel and vehicles to periodic inspections by representatives of the Division for compliance with these rules. If deficiencies are noted, the licensee shall submit an acceptable plan of corrective action, remedy the deficiencies and pay any repeat inspection fees. In addition, each licensee shall submit a renewal form approved by the Division and any applicable renewal fees prior to the expiration date of the license.

2. Upon reapplication, the licensee shall submit its base of operations, stations, and vehicles to inspections by representatives of the Division for compliance with these rules.

3. Ambulance services must show documented proof of annual mandatory random drug screening for licensed employees.

4. An ambulance service may renew the service license within sixty (60) days following the license expiration date upon payment of the renewal fee, in addition to a late penalty established by the Board for each month or fraction of a month that payment for renewal is late, provided that the late penalty shall not exceed twice the renewal fee. If the ambulance service license is not renewed within sixty (60) days following the license expiration date, then the licensee shall reapply for licensure in accordance with the rules established by the Board.

(d) Changes of address, insurance agents or policies, service director, officers, or other service officials, EMS medical director, or bankruptcy filings must be reported to the Division no later than five (5) business days after the change or date of effective action.

(e) A proposed change of ownership, including a change in a controlling interest, must be reported to the Division a minimum of thirty (30) days prior to the change. The Division must receive a new application and fee before the license may be issued.

Notes

Tenn. Comp. R. & Regs. 1200-12-01-.14

Original rule filed November 30, 1984; effective February 12, 1985. Amendment filed March 22, 1985; effective April 21, 1985. Amendment filed June 30, 1987; effective August 14, 1987. Amendment filed September 23, 1991; effective November 7, 1991. Amendment filed October 22, 1993; effective January 5, 1994. Amendment filed March 7, 1994; effective May 21, 1994. Amendment filed January 7, 1997; effective March 23, 1997. Amendment filed May 5, 2014; effective August 3, 2014. Amendment filed May 26, 2010; effective August 24, 2010. Amendments filed September 23, 2019; effective December 22, 2019. Emergency rule filed February 11, 2021; effective through August 10, 2021. Emergency rule expired effective August 11, 2021, and the rule reverted to its previous status. Emergency rules filed November 19, 2021; effective through May 18, 2022. Emergency rules expired effective May 19, 2022, and the rules reverted to their previous statuses. Amendments filed July 20, 2022; effective 10/18/2022.

Authority: T.C.A. §§ 68-140-304, 68-140-305, 68-140-306, and 68-140-307.