6 Colo. Code Regs. § 1015-3-4-14

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1015-3-4-14 - Administrative and Operational Standards for Governance, Patient Records and Record Retention, Personnel, and Policies and Procedures

14.1 Administrative and Operating Standards - Licensees shall maintain administrative policies, procedures and/or operating standards necessary to comply with these rules and in accordance with organizational governance requirements.

14.2 This Section 14 shall be effective on July 1, 2026.

14.3 Ambulance services shall ensure patients the following rights at a minimum:

14.3.1 The right of the patient and their property to be treated, to the extent possible, in a respectful manner that recognizes a person's dignity, cultural values, and religious beliefs, and provides for personal privacy during the course of treatment;

14.3.2 The right of the patient to be free from discrimination in the provision of services;

14.3.3 The right of the patient to be free from neglect; financial exploitation; and verbal, physical, and psychological abuse;

14.3.4 The right of the patient to participate in decisions involving patient care, to the extent possible;

14.3.5 The right of the patient to have personally identifying health information protected from unnecessary disclosure;

14.3.6 The right of the patient or the patient's legal representative to file a complaint with the ambulance service and/or Department concerning services or care that is or is not furnished, without fear of discrimination or retaliation by the ambulance service owner, administrator, EMS providers, or any service staff; and the right to receive notification from the ambulance service and/or Department of the resolution of the complaint.

14.3.7 The right of the patient or the patient's legal representative to obtain medical record information.

14.3.8 The right to receive treatment according to a known, valid medical or behavioral health advance directive, including the right to receive treatment as directed by a legally authorized person pursuant to Colorado Revised Statutes.

14.3.9 The right to receive medical assessment and care delivered by the ambulance service's EMS providers pursuant to their appropriate scopes of practice and in accordance with the needs of the patient, to the extent possible.

14.4 Personnel

14.4.1 General Personnel Standards - At a minimum, each ambulance service shall operate with qualified personnel, including an administrator, a medical director, and EMS providers.

14.4.2 Beginning July 1, 2026, the ambulance service shall:

A) Conduct a licensure/certification check on every prospective employee, contractor, or volunteer who is a licensed or certified EMS provider in Colorado and who will be providing patient care. At a minimum, the ambulance service must review the Department's "OATH-public lookup" or successor database before employment to establish that the provider's license or certification has not been suspended or revoked and has not expired;

B) Conduct a licensure/certification check on every prospective employee, contractor, or volunteer who is an EMS provider and who will be providing patient care with a valid privilege to practice in Colorado pursuant to the EMS Compact. At a minimum, the ambulance service must review the EMS Compact database before employment to establish that the provider's privilege to practice has not been suspended or revoked and has not expired;

C) After conducting the initial licensure/certification check on EMS providers, an ambulance service must, at a minimum, review the Department's "OATH-public lookup" or successor database, or the EMS Compact for out-of-state licensed providers, on an annual basis thereafter to establish that every EMS provider who is employed by, contracts with, or volunteers for the ambulance service maintains a license or certification or has a valid privilege to practice that has not been suspended or revoked, or that has not expired.

14.4.3 Role-Specific Personnel Standards

A) Each ambulance service shall have an administrator who is responsible for the service's day-to-day business operations.

1) Administrator Qualifications. Administrators hired after July 1, 2026, shall:

a) Possess a high school diploma or equivalent; and

b) Have at least six (6) months of health care, emergency medical service, ambulance service, health service administration, or general business experience; and

c) Have not been excluded from participation in Medicare, Medicaid, or state health care programs.

2) The administrator of an ambulance service shall assume daily oversight of the service including, but not limited to, serving as the ambulance service contact person with the Department and maintaining ongoing communications with the Department.

B) Each ambulance service shall have a medical director who is responsible for medical oversight of the service and its EMS providers as provided in Section 11 of this Chapter Four and 6 CCR 1015-3, Chapter Two.

C) All EMS providers hired by, contracted with, or volunteering for the service to provide patient care shall:

1) Have a current license or certification from the state of Colorado pursuant to 6 CCR 1015-3, Chapter One, or have a valid equivalent privilege to practice as an EMS provider under the EMS Compact;

2) Operate only within the scope of practice as outlined in 6 CCR 1015-3, Chapter Two - Rules Pertaining to EMS Practice and Medical Director Oversight, or under scope of practice waivers granted by the Department to the medical director; and

3) Be credentialed to practice by the ambulance service's medical director.

D) All vehicle operators hired by, contracted with, or volunteering for the service after July 1, 2026, shall:

1) Be at least eighteen (18) years of age;

2) Have a currently valid drivers' license as set forth in Sections 42-2-101et seq., C.R.S., with appropriate endorsements for the vehicle class; and

3) Have documentation of successful completion of an agency approved emergency vehicle operation program.

14.4.4 Training and Orientation

A) Beginning July 1, 2026, no employee, contractor, or volunteer shall provide patient care prior to receiving orientation that specifically addresses the following:

1) Matters of confidentiality, safety, and appropriate behavior;

2) The individual's specific duties and responsibilities prior to assuming the role;

3) The service's policies, procedures, and applicable state and federal laws;

4) An overview of state regulatory oversight and, if applicable, local requirements that apply to the ambulance service and EMS provider;

5) Reporting requirements, including mandatory incident reporting as set forth in Section 9 of this Chapter Four; and

6) Patient rights as found in Section 14.3.

14.4.5 Personnel Records

A) Ambulance services shall maintain appropriate and current personnel files for each employee, contractor, and volunteer and shall retain those files for a minimum of three (3) years, or longer if otherwise required, following an employee's, contractor's, or volunteer's separation from service.

14.5 Patient Records and Records Retention

14.5.1 Patient Records - The ambulance service shall implement procedures that establish patient records retention requirements in accordance with state and federal requirements, and at minimum, the following:

A) For purposes of these rules, the ambulance service shall maintain its patient care reports for no less than seven (7) years.

B) If any changes/corrections, deletions, or other modifications are made to any portion of a patient care report:

1) They must be distinctly identified, and

2) The ambulance service must provide a reliable means to clearly identify the original content, the modified content, and the time, date, and authorship of each modification of the record.

14.5.2 Facility Access to Records

A) To facilitate the continuum of care, an ambulance service shall ensure that ambulance service employees, contractors, or volunteers provide receiving facility medical staff, at minimum, with a verbal patient report containing the details of the assessment and care provided to the patient.

B) A verbal patient report shall be followed by submission of patient care data as set forth in Section 10.2.1.

14.5.3 Patient Access to Records - The ambulance service shall implement procedures to allow patient access to the patient's medical records. The policies must include and identify, at a minimum, the method by which the patient or their legal representative may access the patient's medical records upon request.

14.5.4 Equipment and Vehicle Records

A) The ambulance service shall:

1) Require its employees, contractors, or volunteers to conduct and record routine medical equipment and medications checks, the records of which must be maintained for a period of two (2) years;

2) Maintain all vehicle maintenance records associated with each permitted ambulance for the life of the vehicle; and

3) Develop and implement a policy no later than July 1, 2026, regarding routine and scheduled maintenance for each piece of durable medical equipment that is used in each permitted ambulance. The scheduled maintenance must conform to manufacturers' recommendations, and all equipment maintenance records shall be maintained for the life of the equipment.

B) The ambulance service shall make available to the Department for inspection all records required by Section 14.5.4(A) of this Chapter Four upon the Department's request.

14.5.5 Permanent Closures - With regard to any individual patient records that the ambulance service is legally obligated to maintain, each licensee that surrenders its license shall:

A) Inform the Department in writing of the specific plan providing for the storage of and patient access to individual patient records within ten (10) calendar days prior to closure; and

B) Ensure that the disposition of all patient records is in accordance with applicable state and federal law.

14.6 Policies and Procedures - for the convenience of licensees, this section contains 1) a compilation of policies required by these rules that are not set forth in other parts of this rule, and 2) a compilation of policies required by these rules that are set forth in other parts of this rule.

14.6.1 Each ambulance service shall develop in writing and implement policies and procedures for the following matters that are not elsewhere described in these rules:

A) Designating, in policy, the position title or organizational role that will serve as a backup administrator to act in the administrator's absence and who will, at minimum, maintain on-call availability at all hours employees are providing services. The administrator retains accountability for the operations of the ambulance service during the backup administrator's day-to-day supervision and control of the ambulance service.

B) The ambulance service's manner of responding to, investigating, and resolving complaints received to address, at minimum, the procedures by and timeframes in which the ambulance service shall process:

1) Complaint intake;

2) Complaint investigation;

3) Fact-finding and decision-making;

4) Referral of complaints regarding medical care to the QA program;

5) Notification of the complaint resolution with the complainant and the subject of complaint, as applicable;

6) Notification to other entities, if applicable; and

7) Retention of complaint files for at least four (4) years following resolution of the complaint.

C) No later than July 1, 2026, the ambulance service's policy for decommissioning of ambulances to protect the integrity of the EMS system. The policy shall require that when the ambulance service sells, gifts, decommissions, or transfers ownership of an ambulance to an entity other than an ambulance service licensed in Colorado or an equivalent entity in another state or country, or to an EMS educational program for teaching purposes, it shall remove or permanently deface:

1) Characteristics of the vehicle that identify it as an ambulance, including, but not limited to, all instances of the word "ambulance" (including reverse print), medic, paramedic, emergency, star of life emblem, and reflective striping;

2) Emergency lighting that is red or blue in color;

3) Sirens and public address systems; and

4) Other characteristics unique to the ambulance service.

14.6.2 Each ambulance service shall develop in writing and implement these policies and procedures that are referenced elsewhere in this rule, and shall make them available for Department inspection. At a minimum, the policies and procedures shall address:

A) No later than July 1, 2026, the preventative maintenance policy for vehicles and durable medical equipment, and mechanical safety inspection requirements, as set forth in Sections 3.5.2.D, 3.7.2.D, 3.11.1.B, and 14.5.4.A;

B) The minimum equipment requirements for each permitted ambulance as required by Section 13, Sections 3.5.2.D and 3.7.2.F, medical protocols, current emergency medical care standards, and any applicable scope of practice waivers;

C) No later than July 1, 2026, staff training regarding mandatory incident reporting and obligation to report to the ambulance service administrator as set forth in Section 9;

D) The manner in which the ambulance service will ensure the availability of patient care reports to all facilities that cannot otherwise access these reports, as set forth in Section 10.1.1.B;

E) The requirements of the ambulance service's quality assurance program (QA), as set forth in Section 11.3;

F) The ambulance service's staffing pattern and safety considerations as set forth in Section 12.2.1;

G) Communications equipment that meets the minimum standards set forth in Section 13.2.3(A) and (B);

H) Patient rights as set forth in Section 14.3;

I) The ambulance service's patient record retention requirements in accordance with state and federal requirements and Section 14.5;

J) Transfer of care of a patient as set forth in Section 14.5.2; and

K) Access to patient records as set forth in Section 14.5.3.

6 CCR 1015-3-4-14

47 CR 02, January 25, 2024, effective 2/14/2024