SB 1107 - Perfected Bill Text

SECOND REGULAR SESSION

[P E R F E C T E D]

SENATE SUBSTITUTE FOR

SENATE COMMITTEE SUBSTITUTE FOR

SENATE BILL NO. 1107

91ST GENERAL ASSEMBLY

INTRODUCED BY SENATOR CHILDERS.

Offered April 16, 2002.

Senate Substitute adopted, April 16, 2002.

Taken up for Perfection April 16, 2002. Bill declared Perfected and Ordered Printed, as amended.

TERRY L. SPIELER, Secretary.

3922S.07P

AN ACT

To repeal sections 190.044, 190.050, 190.092, 190.094, 190.100, 190.101, 190.102, 190.105, 190.108, 190.109, 190.120, 190.142, 190.143, 190.160, 190.165, 190.171, 190.175, 190.185, 190.196 and 321.130, RSMo, relating to provisions of emergency services, and to enact in lieu thereof thirty-three new sections relating to the same subject, with penalty provisions.

Be it enacted by the General Assembly of the State of Missouri, as follows:

Section A. Sections 190.044, 190.050, 190.092, 190.094, 190.100, 190.101, 190.102, 190.105, 190.108, 190.109, 190.120, 190.142, 190.143, 190.160, 190.165, 190.171, 190.175, 190.185, 190.196 and 321.130, RSMo, are repealed and thirty-three new sections enacted in lieu thereof, to be known as sections 190.050, 190.051, 190.053, 190.054, 190.092, 190.094, 190.100, 190.101, 190.102, 190.105, 190.108, 190.109, 190.120, 190.122, 190.142, 190.143, 190.160, 190.165, 190.171, 190.172, 190.175, 190.185, 190.196, 190.248, 190.525, 190.528, 190.531, 190.534, 190.537, 321.130, 321.552, 321.554 and 321.556, to read as follows:

190.050. 1. After the ambulance district has been declared organized, the declaring county commission, except in counties of the second class having more than one hundred five thousand inhabitants located adjacent to a county of the first class having a charter form of government which has a population of over nine hundred thousand inhabitants, shall divide the district into six election districts as equal in population as possible, and shall by lot number the districts from one to six inclusive. The county commission shall cause an election to be held in the ambulance district within ninety days after the order establishing the ambulance district to elect ambulance district directors. Each voter shall vote for one director from the ambulance election district in which the voter resides. The directors elected from districts one and four shall serve for a term of one year, the directors elected from districts two and five shall serve for a term of two years, and the directors from districts three and six shall serve for a term of three years; thereafter, the terms of all directors shall be three years. All directors shall serve the term to which they were elected or appointed, and until their successors are elected and qualified, except in cases of resignation or disqualification. The county commission shall reapportion the ambulance districts within sixty days after the population of the county is reported to the governor for each decennial census of the United States. Notwithstanding any other provision of law, if the number of candidates for the office of director is no greater than the number of directors to be elected, no election shall be held, and the candidates shall assume the responsibilities of their offices at the same time and in the same manner as if they have been elected.

2. In all counties of the second class having more than one hundred five thousand inhabitants located adjacent to a county of the first class having a charter form of government which has a population of over nine hundred thousand inhabitants, the voters shall vote for six directors elected at large from within the district for a term of three years. Those directors holding office in any district in such a county on August 13, 1976, shall continue to hold office until the expiration of their terms, and their successors shall be elected from the district at large for a term of three years. In any district formed in such counties after August 13, 1976, the governing body of the county shall cause an election to be held in that district within ninety days after the order establishing the ambulance district to elect ambulance district directors. Each voter shall vote for six directors. The two candidates receiving the highest number of votes at such election shall be elected for a term of three years, the two candidates receiving the third and fourth highest number of votes shall be elected for a term of two years, the two candidates receiving the fifth and sixth highest number of votes shall be elected for a term of one year; thereafter, the term of all directors shall be three years.

3. A candidate for director of the ambulance district shall, at the time of filing, be a citizen of the United States, a qualified voter of the election district as provided in subsection 1 of this section, a resident of the [state for one year] district for two years next preceding the election, and shall be at least [twenty-one] twenty-four years of age. In an established district which is located within the jurisdiction of more than one election authority, the candidate shall file his or her declaration of candidacy with the secretary of the board. In all other districts, a candidate shall file [his] a declaration of candidacy with the county clerk of the county in which he or she resides. A candidate shall file a statement under oath that he or she possesses the required qualifications. No candidate's name shall be printed on any official ballot unless the candidate has filed a written declaration of candidacy pursuant to subsection 5 of section 115.127, RSMo. If the time between the county commission's call for a special election and the date of the election is not sufficient to allow compliance with subsection 5 of section 115.127, RSMo, the county commission shall, at the time it calls the special election, set the closing date for filing declarations of candidacy.

190.051. 1. Notwithstanding the provisions of sections 190.050 and 190.052 to the contrary, upon a motion by the board of directors in districts where there are six-member boards, and upon approval by the voters in the district, the number of directors may be increased to seven with one board member running district wide, or decreased to five or three board members. The ballot to be used for the approval of the voters to increase or decrease the number of members on the board of directors of the ambulance district shall be substantially in the following form:

Shall the number of members of the board of directors of the .............. (Insert name of district) Ambulance District be (increased to seven members/decreased to five members/decreased to three members)?

YES NO

2. If a majority of the voters voting on a proposition to increase the number of board members to seven vote in favor of the proposition, then at the next election of board members after the voters vote to increase the number of directors, the voters shall select one person to serve in addition to the existing six directors as the member who shall run district wide.

3. If a majority of the voters voting on a proposition to decrease the number of board members vote in favor of the proposition, then the county clerk shall redraw the district into the resulting number of subdistricts with equal population bases and hold elections by subdistricts pursuant to section 190.050. Thereafter, members of the board shall be elected to serve terms of three years and until their successors are duly elected and qualified.

4. Members of the board of directors in office on the date of an election pursuant to this section to increase or decrease the number of members of the board of directors shall serve the term to which they were elected or appointed and until their successors are elected and qualified.

190.053. 1. Each member of an ambulance district board shall be subject to recall from office by the registered voters of the subdistrict from which he or she was elected. Proceedings may be commenced for the recall of any ambulance district board member by the filing of a notice of intention to circulate a recall petition pursuant to this section and section 190.054.

2. Proceedings may not be commenced against any member if, at the time of commencement, that member:

(1) Has not held office during his or her current term for a period of more than one hundred eighty days; or

(2) Has one hundred eighty days or less remaining in his or her term; or

(3) Has had a recall election determined in his or her favor within the current term of office.

3. The notice of intention to circulate a recall petition shall be served personally, or by certified mail, on the board member sought to be recalled. A copy thereof shall be filed, along with an affidavit of the time and manner of service, with the election authority, as defined in chapter 115, RSMo. A separate notice shall be filed for each board member sought to be recalled and shall contain all of the following:

(1) The name of the board member sought to be recalled;

(2) A statement, not exceeding two hundred words in length, of the reasons for the proposed recall; and

(3) The names and business or residence addresses of at least one and not more than five proponents of the recall.

4. Within seven days after the filing of the notice of intention, the board member may file with the election authority a statement, not exceeding two hundred words in length, in answer to the statement of the proponents. If an answer is filed, the board member shall also serve a copy of it, personally or by certified mail, on one of the proponents named in the notice of intention. The statement and answer are intended solely for the information of the voters. No insufficiency in form or substance of such statements shall affect the validity of the election proceedings.

5. Before any signature may be affixed to a recall petition, the petition must bear all of the following:

(1) A request that an election be called to elect a successor to the board member;

(2) A copy of the notice of intention, including the statement of grounds for recall;

(3) The answer of the board member sought to be recalled, if any. If the board member has not answered, the petition shall so state; and

(4) A place for each signer to affix his or her signature, printed name and residence address, including city or unincorporated community.

6. Each section of the petition, when submitted to the election authority, shall have attached to it an affidavit signed by the circulation of that section, setting forth all of the following:

(1) The printed name of the affiant;

(2) The residence address of the affiant;

(3) That the affiant circulated that section and saw the appended signatures be written;

(4) That according to the best information and belief of the affiant, each signature is the genuine signature of the person whose name it purports to be;

(5) That the affiant is a registered voter of the subdistrict of the board member sought to be recalled; and

(6) The dates between which all the signatures to the petition were obtained.

7. A recall petition shall be filed with the election authority not more than one hundred eighty days after the filing of the notice of intention.

8. The number of qualified signatures required in order to recall a board member shall be equal in number to at least twenty-five percent of the number of voters who voted in the most recent gubernatorial election in that subdistrict.

9. Within twenty days from the filing of the recall petition the election authority shall determine whether or not the petition was signed by the required number of qualified signatures. The election authority shall file with the petition a certificate showing the results of the examination. The authority shall give the proponents a copy of the certificate upon their request.

10. If the election authority certifies the petition to be insufficient, it may be supplemented within ten days of the date of certificate by filing additional petition sections containing all of the information required by this section. Within ten days after the supplemental copies are filed, the election authority shall file with it a certificate stating whether or not the petition as supplemented is sufficient.

11. If the certificate shows that the petition as supplemented is insufficient, no action shall be taken on it; however, the petition shall remain on file.

190.054. 1. If the election authority finds the signatures on the petition described in section 190.053, together with the supplementary petition sections, if any, to be sufficient, it shall submit its certificate as to the sufficiency of the petition to the ambulance district board prior to its next meeting. The certificate shall contain:

(1) The name of the member whose recall is sought;

(2) The number of signatures required by law;

(3) The total number of signatures on the petition; and

(4) The number of valid signatures on the petition.

2. Following the ambulance district board's receipt of the certificate, the election authority shall order an election to be held on one of the election days specified in section 115.123, RSMo. The election shall be held not less than forty-five days nor more than one hundred twenty days after the ambulance district board receives the petition. Nominations pursuant to this section shall be made by filing a statement of candidacy with the election authority.

3. At any time prior to forty-two days before the election, the member sought to be recalled may offer his or her resignation. If his or her resignation is offered, the recall question shall be removed from the ballot and the office declared vacant. The member who resigned may not fill the vacancy, which shall be filled as provided by law.

4. The provisions of chapter 115, RSMo, governing the conduct of elections shall apply, where appropriate, to recall elections held pursuant to this section. The costs of the election shall be paid as provided in chapter 115, RSMo.

190.092. 1. [For purposes of this section, "first responder" shall be defined as a person who has successfully completed an emergency first response course meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.180 and who provides emergency medical care through employment by, or in association with, an emergency medical response agency. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is promulgated under the authority of this chapter, shall become effective only if the agency has fully complied with all of the requirements of chapter 536, RSMo, including but not limited to, section 536.028, RSMo, if applicable, after August 28, 1998. All rulemaking authority delegated prior to August 28, 1998, is of no force and effect and repealed as of August 28, 1998, however nothing in this section shall be interpreted to repeal or affect the validity of any rule adopted and promulgated prior to August 28, 1998. If the provisions of section 536.028, RSMo, apply, the provisions of this section are nonseverable and if any of the powers vested with the general assembly pursuant to section 536.028, RSMo, to review, to delay the effective date, or to disapprove and annul a rule or portion of a rule are held unconstitutional or invalid, the purported grant of rulemaking authority and any rule so proposed and contained in the order of rulemaking shall be invalid and void, except that nothing in this section shall affect the validity of any rule adopted and promulgated prior to August 28, 1998.

2. Any county, municipality or fire protection district may establish a program to allow the use of automated external defibrillators by any person properly qualified who follows medical protocol for use of the device or member of a fire, police, ambulance service, emergency medical response agency or first responder agency provided that such person has completed a course certified by the American Red Cross or American Heart Association that includes cardiopulmonary resuscitation training and demonstrated proficiency in the use of such automated external defibrillators.

3.] A person or entity who acquires an automated external defibrillator shall ensure that:

(1) Expected defibrillator users receive training by the American Red Cross or American Heart Association in cardiopulmonary resuscitation and the use of automated external defibrillators, or an equivalent nationally recognized course in defibrillator use and cardiopulmonary resuscitation;

(2) The defibrillator is maintained and tested according to the manufacturer's operational guidelines;

(3) Any person who renders emergency care or treatment on a person in cardiac arrest by using an automated external defibrillator activates the emergency medical services system as soon as possible; and

(4) Any person or entity that owns an automated external defibrillator that is for use outside of a health care facility shall have a physician [provide medical protocol for the use of the device] review and approve the clinical protocol for the use of the defibrillator, review and advise regarding the training and skill maintenance of the intended users of the defibrillator and assure proper review of all situations when the defibrillator is used to render emergency care.

[4.] 2. Any person or entity who acquires an automated external defibrillator shall notify the emergency communications district or the ambulance dispatch center of the primary provider of emergency medical services where the automated external defibrillator is to be located.

[5.] 3. Any person who has had appropriate training, including a course in cardiopulmonary resuscitation, has demonstrated a proficiency in the use of an automated external defibrillator, and who gratuitously and in good faith renders emergency care when medically appropriate by use of or provision of an automated external defibrillator, without objection of the injured victim or victims thereof, shall not be held liable for any civil damages as a result of such care or treatment, where the person acts as an ordinarily reasonable, prudent person, or with regard to a health care professional, including the licensed physician who reviews and approves the clinical protocol, as a reasonably prudent and careful health care provider would have acted, under the same or similar circumstances. Nothing in this section shall affect any claims brought pursuant to chapter 537 or 538, RSMo.

190.094. In any county of the second classification containing part of a city which is located in four counties and any county bordering said county on the east and south and in any county of the third classification with a population of at least eight thousand four hundred but less than eight thousand five hundred inhabitants containing part of a lake of nine hundred fifty-eight miles of shoreline but less than one thousand miles of shoreline each ambulance, when in use as an ambulance, shall be staffed with a minimum of one emergency medical technician and one other crew member as set forth in rules adopted by the department. When transporting a patient, at least one licensed emergency medical technician, [mobile emergency medical technician,] registered nurse or physician shall be in attendance with the patient in the patient compartment at all times.

190.100. As used in sections 190.001 to 190.245, the following words and terms mean:

(1) "Advanced life support (ALS)", an advanced level of care as provided to the adult and pediatric patient such as defined by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;

(2) "Ambulance", any privately or publicly owned vehicle or craft that is specially designed, constructed or modified, staffed or equipped for, and is intended or used, maintained or operated for the transportation of persons who are sick, injured, wounded or otherwise incapacitated or helpless, or who require the presence of medical equipment being used on such individuals, but the term does not include any motor vehicle specially designed, constructed or converted for the regular transportation of persons who are disabled, handicapped, normally using a wheelchair, or otherwise not acutely ill, or emergency vehicles used within airports;

(3) "Ambulance service", a person or entity that provides emergency or nonemergency ambulance transportation and services, or both, in compliance with sections 190.001 to 190.245, and the rules promulgated by the department pursuant to sections 190.001 to 190.245;

(4) "Ambulance service area", a specific geographic area in which an ambulance service has been authorized to operate;

(5) "Basic life support (BLS)", a basic level of care, as provided to the adult and pediatric patient as defined by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;

(6) "Council", the state advisory council on emergency medical services;

(7) "Department", the department of health and senior services, state of Missouri;

(8) "Director", the director of the department of health and senior services or the director's duly authorized representative;

(9) "Dispatch agency", any person or organization that receives requests for emergency medical services from the public, by telephone or other means, and is responsible for dispatching emergency medical services;

(10) "Emergency", the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity that would lead a prudent layperson, possessing an average knowledge of health and medicine, to believe that the absence of immediate medical care could result in:

(a) Placing the person's health, or with respect to a pregnant woman, the health of the woman or her unborn child, in significant jeopardy;

(b) Serious impairment to a bodily function;

(d) Inadequately controlled pain;

(11) "Emergency medical dispatcher", a person who receives emergency calls from the public and has successfully completed an emergency medical dispatcher course, meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245;

(12) "Emergency medical response agency", any person that regularly provides a level of care that includes first response, basic life support or advanced life support, exclusive of patient transportation;

(13) "Emergency medical services for children (EMS-C) system", the arrangement of personnel, facilities and equipment for effective and coordinated delivery of pediatric emergency medical services required in prevention and management of incidents which occur as a result of a medical emergency or of an injury event, natural disaster or similar situation;

(14) "Emergency medical services (EMS) system", the arrangement of personnel, facilities and equipment for the effective and coordinated delivery of emergency medical services required in prevention and management of incidents occurring as a result of an illness, injury, natural disaster or similar situation;

(15) "Emergency medical technician", a person licensed in emergency medical care in accordance with standards prescribed by sections 190.001 to 190.245, and by rules adopted by the department pursuant to sections 190.001 to 190.245;

(16) "Emergency medical technician-basic" or "EMT-B", a person who has successfully completed a course of instruction in basic life support as prescribed by the department and is licensed by the department in accordance with standards prescribed by sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;

(17) "Emergency medical technician-paramedic" or "EMT-P", a person who has successfully completed a course of instruction in advanced life support care as prescribed by the department and is licensed by the department in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;

(18) "Emergency services", health care items and services furnished or required to screen and stabilize an emergency which may include, but shall not be limited to, health care services that are provided in a licensed hospital's emergency facility by an appropriate provider or by an ambulance service or emergency medical response agency;

(19) "First responder", a person who has successfully completed an emergency first response course meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245 and who provides emergency medical care through employment by or in association with an emergency medical response agency;

(20) "Health care facility", a hospital, nursing home, physician's office or other fixed location at which medical and health care services are performed;

(21) "Hospital", an establishment as defined in the hospital licensing law, subsection 2 of section 197.020, RSMo, or a hospital operated by the state;

(22) "Medical control", supervision provided by or under the direction of physicians to providers by written or verbal communications;

(23) "Medical direction", medical guidance and supervision provided by a physician to an emergency services provider or emergency medical services system;

(24) "Medical director", a physician licensed pursuant to chapter 334, RSMo, designated by the ambulance service or emergency medical response agency and who meets criteria specified by the department by rules pursuant to sections 190.001 to 190.245;

(25) "Memorandum of understanding", an agreement between an emergency medical response agency or dispatch agency and an ambulance service or services within whose territory the agency operates, in order to coordinate emergency medical services;

(26) "Patient", an individual who is sick, injured, wounded, diseased, or otherwise incapacitated or helpless, or dead, excluding deceased individuals being transported from or between private or public institutions, homes or cemeteries, and individuals declared dead prior to the time an ambulance is called for assistance;

(27) "Person", as used in these definitions and elsewhere in sections 190.001 to 190.245, any individual, firm, partnership, copartnership, joint venture, association, cooperative organization, corporation, municipal or private, and whether organized for profit or not, state, county, political subdivision, state department, commission, board, bureau or fraternal organization, estate, public trust, business or common law trust, receiver, assignee for the benefit of creditors, trustee or trustee in bankruptcy, or any other service user or provider;

(28) "Physician", a person licensed as a physician pursuant to chapter 334, RSMo;

(29) "Political subdivision", any municipality, city, county, city not within a county, ambulance district or fire protection district located in this state which provides or has authority to provide ambulance service;

(30) "Professional organization", any organized group or association with an ongoing interest regarding emergency medical services. Such groups and associations could include those representing volunteers, labor, management, firefighters, EMT-B's, nurses, EMT-P's, physicians, communications specialists and instructors. Organizations could also represent the interests of ground ambulance services, air ambulance services, fire service organizations, law enforcement, hospitals, trauma centers, communication centers, pediatric services, labor unions and poison control services;

(31) "Proof of financial responsibility", proof of ability to respond to damages for liability, on account of accidents occurring subsequent to the effective date of such proof, arising out of the ownership, maintenance or use of a motor vehicle in the financial amount set in rules promulgated by the department, but in no event less than the statutory minimum required for motor vehicles. Proof of financial responsibility shall be used as proof of self-insurance;

(32) "Protocol", a predetermined, written medical care guideline, which may include standing orders;

[(32)] (33) "Regional EMS advisory committee", a committee formed within an emergency medical services (EMS) region to advise ambulance services, the state advisory council on EMS and the department;

[(33)] (34) "Stabilize", with respect to an emergency, the provision of such medical treatment as may be necessary to attempt to assure within reasonable medical probability that no material deterioration of an individual's medical condition is likely to result from or occur during ambulance transportation unless the likely benefits of such transportation outweigh the risks;

[(34)] (35) "State advisory council on emergency medical services", a committee formed to advise the department on policy affecting emergency medical service throughout the state;

[(35)] (36) "State EMS medical directors advisory committee", a subcommittee of the state advisory council on emergency medical services formed to advise the state advisory council on emergency medical services and the department on medical issues;

[(36)] (37) "Trauma", an injury to human tissues and organs resulting from the transfer of energy from the environment;

[(37)] (38) "Trauma care" includes injury prevention, triage, acute care and rehabilitative services for major single system or multisystem injuries that potentially require immediate medical or surgical intervention or treatment;

[(38)] (39) "Trauma center", a hospital that is currently designated as such by the department.

190.101. 1. There is hereby established a "State Advisory Council on Emergency Medical Services" which shall consist of fifteen members. The members of the council shall be appointed by the governor with the advice and consent of the senate and shall serve terms of four years. The governor shall designate one of the members as chairperson. The chairperson may appoint subcommittees that include noncouncil members.

2. The state EMS medical directors advisory committee and the regional EMS advisory committees will be recognized as subcommittees of the state advisory council on emergency medical services.

3. The council shall have geographical representation and representation from appropriate areas of expertise in emergency medical services including volunteers, professional organizations involved in emergency medical services, EMT's, paramedics, nurses, firefighters, air ambulance, physicians, ambulance service administrators, hospital administrators and other health care providers concerned with emergency medical services. The regional EMS advisory committees shall serve as a resource for the identification of potential members of the state advisory council on emergency medical services.

4. The members of the council and subcommittees shall serve without compensation except that the department of health and senior services shall budget for reasonable travel expenses and meeting expenses related to the functions of the council.

5. The purpose of the council is to make recommendations to the governor, the general assembly, and the department on policies, plans, procedures and proposed regulations on how to improve the statewide emergency medical services system. The council shall advise the governor, the general assembly, and the department on all aspects of the emergency medical services system.

190.102. 1. The department shall designate through regulation EMS regions and committees. The purpose of the regional EMS advisory committees is to advise and make recommendations to the region and the department on:

(1) Coordination of emergency resources in the region;

(2) Improvement of public and professional education;

(3) Cooperative research endeavors;

(4) Development of standards, protocols and policies; and

(5) Voluntary multiagency quality improvement committee and process.

2. The members of the committees shall serve without compensation except that the department of health and senior services shall budget for reasonable travel expenses and meeting expenses related to the functions of the committees.

3. The director will appoint personnel to no less than six regional EMS committees from recommendations provided by recognized professional organizations. Appointments will be for four years with individuals serving until reappointed or replaced. At least one member of each regional EMS committee shall be associated with an air ambulance service, which is accredited by a nationally recognized air ambulance accrediting organization.

190.105. 1. No person, either as owner, agent or otherwise, shall furnish, operate, conduct, maintain, advertise, or otherwise be engaged in or profess to be engaged in the business or service of the transportation of patients by ambulance in the air, upon the streets, alleys, or any public way or place of the state of Missouri unless such person holds a currently valid license from the department for an ambulance service issued pursuant to the provisions of sections 190.001 to 190.245.

2. No ground ambulance shall be operated for ambulance purposes, and no individual shall drive, attend or permit it to be operated for such purposes in the state of Missouri unless the ground ambulance is under the immediate supervision and direction of a person who is holding a currently valid Missouri license as an emergency medical technician[; except that]. Nothing in this section shall be construed to mean that a duly registered nurse or a duly licensed physician be required to hold an emergency medical technician's license. Each ambulance service is responsible for assuring that any person driving its ambulance is competent in emergency vehicle operations and has a safe driving record. Each ground ambulance shall be staffed with at least two licensed individuals when transporting a patient, except as provided in section 190.094.

3. No license shall be required for an ambulance service, or for the attendant of an ambulance, which:

(1) Is rendering assistance in the case of an emergency, major catastrophe or any other unforeseen event or series of events which jeopardizes the ability of the local ambulance service to promptly respond to emergencies; or

(2) Is operated from a location or headquarters outside of Missouri in order to transport patients who are picked up beyond the limits of Missouri to locations within or outside of Missouri, but no such outside ambulance shall be used to pick up patients within Missouri for transportation to locations within Missouri, except as provided in subdivision (1) of this subsection.

4. The issuance of a license [under] pursuant to the provisions of sections 190.001 to 190.245 shall not be construed so as to authorize any person to provide ambulance services or to operate any ambulances without a franchise in any city not within a county or in a political subdivision in any county with a population of over nine hundred thousand inhabitants, or a franchise, contract or mutual-aid agreement in any other political subdivision which has enacted an ordinance making it unlawful to do so.

5. Sections 190.001 to 190.245 shall not preclude the adoption of any law, ordinance or regulation not in conflict with such sections by any city not within a county, or at least as strict as such sections by any county, municipality or political subdivision except that no such regulations or ordinances shall be adopted by a political subdivision in a county with a population of over nine hundred thousand inhabitants except by the county's governing body.

6. In a county with a population of over nine hundred thousand inhabitants, the governing body of the county shall set the standards for all ambulance services which shall comply with subsection 5 of this section. All such ambulance services must be licensed by the department. The governing body of such county shall not prohibit a licensed ambulance service from operating in the county, as long as the ambulance service meets county standards.

7. An ambulance service or vehicle when operated for the purpose of transporting persons who are sick, injured, or otherwise incapacitated shall not be treated as a common or contract carrier under the jurisdiction of the Missouri [public service commission] division of motor carrier and railroad safety.

8. Sections 190.001 to 190.245 shall not apply to, nor be construed to include, any motor vehicle used by an employer for the transportation of such employer's employees whose illness or injury occurs on private property, and not on a public highway or property, nor to any person operating such a motor vehicle.

9. A political subdivision that is authorized to operate a licensed ambulance service may establish, operate, maintain and manage its ambulance service, and select and contract with a licensed ambulance service. Any political subdivision may contract with a licensed ambulance service.

10. Except as provided in subsections 5 and 6, nothing in section 67.300, RSMo, or subsection 2 of section 190.109, shall be construed to authorize any municipality or county which is located within an ambulance district or a fire protection district that is authorized to provide ambulance service to promulgate laws, ordinances or regulations related to the provision of ambulance services. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1998.

11. Nothing in section 67.300, RSMo, or subsection 2 of section 190.109 shall be construed to authorize any municipality or county which is located within an ambulance district or a fire protection district that is authorized to provide ambulance service to operate an ambulance service without a franchise in an ambulance district or a fire protection district that is authorized to provide ambulance service which has enacted an ordinance making it unlawful to do so. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1998.

12. No provider of ambulance service within the state of Missouri which is licensed by the department to provide such service shall discriminate regarding treatment or transportation of emergency patients on the basis of race, sex, age, color, religion, sexual preference, national origin, ancestry, handicap, medical condition or ability to pay.

13. No provision of this section, other than subsections 5, 6, 10 and 11 of this section, is intended to limit or supersede the powers given to ambulance districts pursuant to this chapter or to fire protection districts pursuant to chapter 321, RSMo, or to counties, cities, towns and villages pursuant to chapter 67, RSMo.

14. Upon the sale or transfer of any ground ambulance service ownership, the owner of such service shall notify the department of the change in ownership within thirty days of such sale or transfer. After receipt of such notice, the department shall conduct an inspection of the ambulance service to verify compliance with the licensure standards of sections 190.001 to 190.245.

190.108. 1. The department shall, within a reasonable time after receipt of an application, cause such investigation as the department deems necessary to be made of the applicant for an air ambulance license.

2. The department shall have the authority and responsibility to license an air ambulance service in accordance with sections 190.001 to 190.245, and in accordance with rules adopted by the department pursuant to sections 190.001 to 190.245. The department may promulgate rules relating to the requirements for an air ambulance license including, but not limited to:

(1) Medical control plans;

(2) Medical director qualifications;

(3) Air medical staff qualifications;

(4) Response and operations standards to assure that the health and safety needs of the public are met;

(5) Standards for air medical communications;

(6) Criteria for compliance with licensure requirements;

(7) Records and forms;

(8) Equipment requirements;

(9) Five-year license renewal;

(10) Quality improvement committees; and

(11) Response time, patient care and transportation standards.

3. Application for an air ambulance service license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.001 to 190.245. The application form shall contain such information as the department deems necessary to make a determination as to whether the air ambulance service meets all the requirements of sections 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245.

4. Upon the sale or transfer of any air ambulance service ownership, the owner of such service shall notify the department of the change in ownership within thirty days of such sale or transfer. After receipt of such notice, the department shall conduct an inspection of the ambulance service to verify compliance with the licensure standards of sections 190.001 to 190.245.

5. Prior to the first day of January of the year 2003, and every five years thereafter, the department shall, by rule and regulation, select one or more nationally recognized aeromedical transport accreditation organizations, the purpose of which is to improve the quality of patient care and safety of medical transport services. Said organization or organizations shall have accreditation standards which substantially include the criteria which the department determines is relevant for the following topics: general standards including capabilities and resources of the service, medical personnel, medical director, medical control physician, clinical care supervisor, staffing and physical requirements, mission types, initial and continuing education, aircraft or ambulance section, medical configurations, operational issues, equipment, communications, management and administration, management or policies, quality management, safety committee and infection control; rotorwing standards including FAA certificate, aircraft, weather and weather minimums, pilot staffing and training, maintenance, helipad, refueling and community outreach; fixed wing standards including FAA certificate, aircraft, weather, weather, pilot staffing and training, policies, maintenance, refueling and community outreach; and ground interfacility standards including vehicles, qualifications of drivers, maintenance and sanitation, mechanic and policies. Said organization or organizations shall evaluate compliance with accreditations standards in order to determine the accredited program's ability to deliver services of a specific quality. Said organization or organizations shall serve no less than twenty-five percent of the air ambulance services of the United States which are nationally accredited.

6. By rule and regulation, the department shall determine reasonably expeditious criterion that shall not exceed two years, for air ambulance services to demonstrate that they are seeking accreditation by the selected nationally recognized aeromedical transport accreditation organization or organizations. After the first day of June of the year 2003, no air ambulance provider shall be eligible for or receive Medicaid reimbursement, receive or renew an air ambulance license unless it has demonstrated to the department that it is accredited or has formally applied for accreditation by a select nationally recognized aeromedical transport accreditation organization or organizations.

7. By rule and regulation, the department shall determine what provisions of sections 190.001 to 190.245 are substantially met by accreditation pursuant to subsections 5 and 6 of this section and waive said provisions for accredited air ambulance providers. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

190.109. 1. The department shall, within a reasonable time after receipt of an application, cause such investigation as the department deems necessary to be made of the applicant for a ground ambulance license.

2. Any person that owned and operated a licensed ambulance on December 31, 1997, shall receive an ambulance service license from the department, unless suspended, revoked or terminated, for that ambulance service area which was, on December 31, 1997, described and filed with the department as the primary service area for its licensed ambulances on August 28, 1998, provided that the person makes application and adheres to the rules and regulations promulgated by the department pursuant to sections 190.001 to 190.245.

3. The department shall issue a new ground ambulance service license to an ambulance service that is not currently licensed by the department, or is currently licensed by the department and is seeking to expand its ambulance service area, except as provided in subsection 4 of this section, to be valid for a period of five years, unless suspended, revoked or terminated, when the director finds that the applicant meets the requirements of ambulance service licensure established pursuant to sections 190.100 to 190.245 and the rules adopted by the department pursuant to sections 190.001 to 190.245. In order to be considered for a new ambulance service license, an ambulance service shall submit to the department a letter of endorsement from each ambulance district or fire protection district that is authorized to provide ambulance service, or from each municipality not within an ambulance district or fire protection district that is authorized to provide ambulance service, in which the ambulance service proposes to operate. If an ambulance service proposes to operate in unincorporated portions of a county not within an ambulance district or fire protection district that is authorized to provide ambulance service, in order to be considered for a new ambulance service license, the ambulance service shall submit to the department a letter of endorsement from the county. Any letter of endorsement required pursuant to this section shall verify that the political subdivision has conducted a public hearing regarding the endorsement and that the governing body of the political subdivision has adopted a resolution approving the endorsement. The letter of endorsement shall affirmatively state that the proposed ambulance service:

(1) Will provide a benefit to public health that outweighs the associated costs;

(2) Will maintain or enhance the public's access to ambulance services;

(3) Will maintain or improve the public health and promote the continued development of the regional emergency medical service system;

(4) Has demonstrated the appropriate expertise in the operation of ambulance services; and

(5) Has demonstrated the financial resources necessary for the operation of the proposed ambulance service.

4. A contract between a political subdivision and a licensed ambulance service for the provision of ambulance services for that political subdivision shall expand, without further action by the department, the ambulance service area of the licensed ambulance service to include the jurisdictional boundaries of the political subdivision. The termination of the aforementioned contract shall result in a reduction of the licensed ambulance service's ambulance service area by removing the geographic area of the political subdivision from its ambulance service area, except that licensed ambulance service providers may provide ambulance services as are needed at and around the state fair grounds for protection of attendees at the state fair.

5. The department shall renew a ground ambulance service license if the applicant meets the requirements established pursuant to sections 190.001 to 190.245, and the rules adopted by the department pursuant to sections 190.001 to 190.245.

6. The department shall promulgate rules relating to the requirements for a ground ambulance service license including, but not limited to:

(1) Vehicle design, specification, operation and maintenance standards;

(2) Equipment requirements;

(3) Staffing requirements;

(4) Five-year license renewal;

(5) Records and forms;

(6) Medical control plans;

(7) Medical director qualifications;

(8) Standards for medical communications;

(9) Memorandums of understanding with emergency medical response agencies that provide advanced life support;

(10) Quality improvement committees; and

(11) Response time, patient care and transportation standards.

7. Application for a ground ambulance service license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.001 to 190.245. The application form shall contain such information as the department deems necessary to make a determination as to whether the ground ambulance service meets all the requirements of sections 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245.

190.120. 1. No ambulance service license shall be issued pursuant to sections 190.001 to 190.245, nor shall such license be valid after issuance, nor shall any ambulance be operated in Missouri unless there is at all times in force and effect insurance coverage [issued by an insurance company] or proof of financial responsibility with adequate reserves maintained for each and every ambulance owned or operated by or for the applicant or licensee[, or unless any city not within a county which owns or operates the license has at all times sufficient self-insurance coverage] to provide for the payment of damages in an amount as prescribed in regulation:

(1) For injury to or death of individuals in accidents resulting from any cause for which the owner of [said] such vehicle would be liable on account of liability imposed on him or her by law, regardless of whether the ambulance was being driven by the owner or the owner's agent; and

(2) For the loss of or damage to the property of another, including personal property, under like circumstances.

2. The insurance policy[, or in the case of a self-insured city not within a county, proof of self-insurance,] or proof of financial responsibility shall be submitted by all licensees required to provide such insurance pursuant to sections 190.001 to 190.245. The insurance policy, or proof of the existence of [self-insurance of a city not within a county] financial responsibility, shall be submitted to the director, in such form as the director may specify, for the director's approval prior to the issuance of each ambulance service license.

3. Every insurance policy or proof of financial responsibility document required by the provisions of this section shall contain [or in the case of a self-insured city not within a county shall have] proof of a provision for a continuing liability thereunder to the full amount thereof, notwithstanding any recovery thereon; that the liability of the insurer shall not be affected by the insolvency or the bankruptcy of the assured; and that until the policy is revoked the insurance company or self-insured [city not within a county] licensee or entity will not be relieved from liability on account of nonpayment of premium, failure to renew license at the end of the year, or any act or omission of the named assured. Such policy of insurance or self-insurance shall be further conditioned for the payment of any judgments up to the limits of [said] such policy, recovered against any person other than the owner, the owner's agent or employee, who may operate the same with the consent of the owner.

4. Every insurance policy or self-insured [city not within a county] licensee or entity as required by the provisions of this section shall extend for the period to be covered by the license applied for and the insurer shall be obligated to give not less than thirty days' written notice to the director and to the insured before any cancellation or termination thereof earlier than its expiration date, and the cancellation or other termination of any such policy shall automatically revoke and terminate the licenses issued for the ambulance service covered by such policy unless covered by another insurance policy in compliance with sections 190.001 to 190.245.

5. Each licensed air ambulance provider shall carry a minimum of twenty million dollars in general liability insurance, which shall include coverage for damage to building caused by the impact of an aircraft.

190.122. All aircraft used for air ambulance service and all personnel providing air ambulance services shall comply with all the requirements to provide advanced life support level of care.

190.142. 1. The department shall, within a reasonable time after receipt of an application, cause such investigation as it deems necessary to be made of the applicant for an emergency medical technician's license. The director may authorize investigations into criminal records in other states for any applicant.

2. The department shall issue a license to all levels of emergency medical technicians, for a period of five years, if the applicant meets the requirements established pursuant to sections 190.001 to 190.245 and the rules adopted by the department pursuant to sections 190.001 to 190.245. The department may promulgate rules relating to the requirements for an emergency medical technician including but not limited to:

(1) Age requirements;

(2) Education and training requirements based on respective national curricula of the United States Department of Transportation and any modification to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245;

(3) Initial licensure testing requirements;

(4) Continuing education and relicensure requirements; and

(5) Ability to speak, read and write the English language.

3. Application for all levels of emergency medical technician license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.001 to 190.245. The application form shall contain such information as the department deems necessary to make a determination as to whether the emergency medical technician meets all the requirements of sections 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245.

4. All levels of emergency medical technicians may perform only that patient care which is:

(1) Consistent with the training, education and experience of the particular emergency medical technician; [and]

(2) Ordered by a physician or set forth in protocols approved by the medical director[.]; and

(3) In an emergency situation providing pre-hospital care, or during continued emergency care in a health care facility, notwithstanding other provisions of law.

5. No person shall hold themselves out as an emergency medical technician or provide the services of an emergency medical technician unless such person is licensed by the department.

6. [All patients transported in a supine position in a vehicle other than an ambulance shall receive an appropriate level of care. The department shall promulgate rules regarding the provisions of this section. This subsection shall only apply to vehicles transporting patients for a fee.] Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

190.143. 1. Notwithstanding any other provisions of law, the department may grant a ninety-day temporary emergency medical technician license to all levels of emergency medical technicians who meet the following:

(1) Can demonstrate that they have, or will have employment requiring an emergency medical technician license;

(2) Are not currently licensed as an emergency medical technician in Missouri or have been licensed as an emergency medical technician in Missouri and fingerprints need to be submitted to the Federal Bureau of Investigation to verify the existence or absence of a criminal history, or they are currently licensed and the license will expire before a verification can be completed of the existence or absence of a criminal history;

(3) Have submitted a complete application upon such forms as prescribed by the department in rules adopted pursuant to sections 190.001 to 190.245;

(4) Have not been disciplined pursuant to sections 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245;

(5) Meet all the requirements of rules promulgated pursuant to sections 190.001 to 190.245.

2. A temporary emergency medical technician license shall only authorize the license to practice while under the immediate supervision of a licensed emergency medical technician-basic, emergency medical technician-paramedic, registered nurse or physician who is currently licensed, without restrictions, to practice in Missouri.

3. A temporary emergency medical technician license shall automatically expire either ninety days from the date of issuance or upon the issuance of a five-year emergency medical technician license.

190.160. The renewal of any license shall require conformance with sections 190.001 to 190.245 and sections 190.525 to 190.537, and rules adopted by the department pursuant to sections 190.001 to 190.245 and sections 190.525 to 190.537.

190.165. 1. The department may refuse to issue or deny renewal of any certificate, permit or license required pursuant to sections 190.100 to 190.245 for failure to comply with the provisions of [this act] sections 190.100 to 190.245 or any lawful regulations promulgated by the department to implement its provisions as described in subsection 2 of this section. The department shall notify the applicant in writing of the reasons for the refusal and shall advise the applicant of his or her right to file a complaint with the administrative hearing commission as provided by chapter 621, RSMo.

2. The department may cause a complaint to be filed with the administrative hearing commission as provided by chapter 621, RSMo, against any holder of any certificate, permit or license required by sections 190.100 to 190.245 or any person who has failed to renew or has surrendered his or her certificate, permit or license for failure to comply with the provisions of sections 190.100 to 190.245 or any lawful regulations promulgated by the department to implement such sections. Those regulations shall be limited to the following:

(1) Use or unlawful possession of any controlled substance, as defined in chapter 195, RSMo, or alcoholic beverage to an extent that such use impairs a person's ability to perform the work of any activity licensed or regulated by sections 190.100 to 190.245;

(2) Being finally adjudicated and found guilty, or having entered a plea of guilty or nolo contendere, in a criminal prosecution under the laws of any state or of the United States, for any offense reasonably related to the qualifications, functions or duties of any activity licensed or regulated pursuant to sections 190.100 to 190.245, for any offense an essential element of which is fraud, dishonesty or an act of violence, or for any offense involving moral turpitude, whether or not sentence is imposed;

(3) Use of fraud, deception, misrepresentation or bribery in securing any certificate, permit or license issued pursuant to sections 190.100 to 190.245 or in obtaining permission to take any examination given or required pursuant to sections 190.100 to 190.245;

(4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception or misrepresentation;

(5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance of the functions or duties of any activity licensed or regulated by sections 190.100 to 190.245;

(6) Violation of, or assisting or enabling any person to violate, any provision of sections 190.100 to 190.245, or of any lawful rule or regulation adopted by the department pursuant to sections 190.100 to 190.245;

(7) Impersonation of any person holding a certificate, permit or license or allowing any person to use his or her certificate, permit, license or diploma from any school;

(8) Disciplinary action against the holder of a license or other right to practice any activity regulated by sections 190.100 to 190.245 granted by another state, territory, federal agency or country upon grounds for which revocation or suspension is authorized in this state;

(9) For an individual being finally adjudged insane or incompetent by a court of competent jurisdiction;

(10) Assisting or enabling any person to practice or offer to practice any activity licensed or regulated by sections 190.100 to 190.245 who is not licensed and currently eligible to practice pursuant to sections 190.100 to 190.245;

(11) Issuance of a certificate, permit or license based upon a material mistake of fact;

(12) Violation of any professional trust or confidence;

(13) Use of any advertisement or solicitation which is false, misleading or deceptive to the general public or persons to whom the advertisement or solicitation is primarily directed;

(14) Violation of the drug laws or rules and regulations of this state, any other state or the federal government;

(15) Refusal of any applicant or licensee to cooperate with the department of health and senior services during any investigation;

(16) Any conduct or practice which is or might be harmful or dangerous to the mental or physical health of a patient or the public;

(17) Repeated negligence in the performance of the functions or duties of any activity licensed or regulated by sections 190.100 to 190.245.

3. After the filing of such complaint, the proceedings shall be conducted in accordance with the provisions of chapter 621, RSMo. Upon a finding by the administrative hearing commission that the grounds, provided in subsection 2 of this section, for disciplinary action are met, the department may, singly or in combination, censure or place the person named in the complaint on probation on such terms and conditions as the department deems appropriate for a period not to exceed five years, or may suspend, for a period not to exceed three years, or revoke the license, certificate or permit.

4. An individual whose license has been revoked shall wait one year from the date of revocation to apply for relicensure. Relicensure shall be at the discretion of the department after compliance with all the requirements of sections 190.100 to 190.245 relative to the licensing of an applicant for the first time. Any individual whose license has been revoked twice within a ten-year period shall not be eligible for relicensure.

5. The department may notify the proper licensing authority of any other state in which the person whose license was suspended or revoked was also licensed of the suspension or revocation.

6. Any person, organization, association or corporation who reports or provides information to the department pursuant to the provisions of sections 190.100 to 190.245 and who does so in good faith shall not be subject to an action for civil damages as a result thereof.

7. The department of health and senior services may suspend any certificate, permit or license required pursuant to sections 190.100 to 190.245 simultaneously with the filing of the complaint with the administrative hearing commission as set forth in subsection 2 of this section, if the department finds that there is an imminent threat to the public health. The notice of suspension shall include the basis of the suspension and notice of the right to appeal such suspension. The licensee may appeal the decision to suspend the license, certificate or permit to the department. The appeal shall be filed within ten days from the date of the filing of the complaint. A hearing shall be conducted by the department within ten days from the date the appeal is filed. The suspension shall continue in effect until the conclusion of the proceedings, including review thereof, unless sooner withdrawn by the department, dissolved by a court of competent jurisdiction or stayed by the administrative hearing commission.

190.171. Any person aggrieved by an official action of the department of health and senior services affecting the licensed status of a person [under] pursuant to the provisions of sections 190.001 to 190.245 and sections 190.525 to 190.537, including the refusal to grant, the grant, the revocation, the suspension, or the failure to renew a license, may seek a determination thereon by the administrative hearing commission pursuant to the provisions of section 621.045, RSMo, and it shall not be a condition to such determination that the person aggrieved seek a reconsideration, a rehearing, or exhaust any other procedure within the department of health and senior services or the department of social services.

190.172. Notwithstanding the provisions of subdivision (3) of subsection 3 of section 621.045, RSMo, to the contrary, if no contested case has been filed against the licensee, the agency shall submit a copy of the settlement agreement signed by all of the parties within fifteen days after signature to the administrative hearing commission for determination that the facts agreed to by the parties to the settlement constitute grounds for denying or disciplining the license of the licensee. Any person who is directly harmed by the specific conduct for which the discipline is sought may submit a written impact statement to the administrative hearing commission for consideration in connection with the commission's review of the settlement agreement.

190.175. 1. Each ambulance service licensee or emergency medical response agency licensee shall maintain accurate records, which contain information concerning the care and, if applicable, the transportation of each patient.

2. Records will be retained by the ambulance service licensees and emergency medical response agency licensees for five years, readily available for inspection by the department, notwithstanding transfer, sale or discontinuance of the ambulance services or business.

3. [An ambulance] A patient care report, approved by the department, shall be completed for each ambulance run on which are entered pertinent remarks by the emergency medical technician, registered nurse or physician and such other items as specified by rules promulgated by the department.

4. A written or electronic patient care document shall be completed and given to the ambulance service personnel by the health care facility when a patient is transferred between health care facilities. Such patient care record shall contain such information pertinent to the continued care of the patient as well as the health and safety of the ambulance service personnel during the transport. Nothing in this section shall be construed as to limit the reporting requirements established in federal law relating to the transfer of patients between health care facilities.

5. Such records shall be available for inspection by the department at any reasonable time during business hours.

190.185. The department shall adopt, amend, promulgate, and enforce such rules, regulations and standards with respect to the provisions of this chapter as may be designed to further the accomplishment of the purpose of this law in promoting state-of-the-art emergency medical services in the interest of public health, safety and welfare. When promulgating such rules and regulations, the department shall consider the recommendations of the state advisory council on emergency medical services. [No] Any rule or portion of a rule promulgated pursuant to the authority of sections 190.001 to 190.245 or sections 190.525 to 190.537 shall become effective [unless it has been promulgated pursuant to the provisions of chapter 536, RSMo] only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

190.196. 1. No employer shall knowingly employ or permit any employee to perform any services for which a license, certificate or other authorization is required by sections 190.001 to 190.245, or by rules adopted pursuant to sections 190.001 to 190.245, unless and until the person so employed possesses all licenses, certificates or authorizations that are required.

2. Any person or entity that employs or supervises a person's activities as a first responder [or], emergency medical dispatcher, emergency medical technician-basic, emergency medical technician-paramedic, registered nurse or physician shall cooperate with the department's efforts to monitor and enforce compliance by those individuals subject to the requirements of sections 190.001 to 190.245.

3. Any person or entity who employs individuals licensed by the department pursuant to sections 190.001 to 190.245 shall report to the department within seventy-two hours of their having knowledge of any charges filed against a licensee in their employ for possible criminal action involving the following felony offenses:

(1) Child abuse or sexual abuse of a child;

(2) Crimes of violence; or

(3) Rape or sexual abuse.

4. Any licensee who has charges filed against him or her for the felony offenses in subsection 3 of this section shall report such an occurrence to the department within seventy-two hours of the charges being filed.

5. The department will monitor these reports for possible licensure action authorized pursuant to section 190.165.

190.248. 1. All investigations conducted in response to allegations of violations of sections 190.001 to 190.245 shall be completed within six months of receipt of the allegation.

2. In the course of an investigation the department shall have access to all records directly related to the alleged violations from persons or entities licensed pursuant to this chapter or chapter 197 or 198, RSMo.

3. Any department investigations that involve other administrative or law enforcement agencies shall be completed within six months of notification and final determination by such administrative or law enforcement agencies.

190.525. As used in sections 190.525 to 190.537, the following terms mean:

(1) "Department", the department of health and senior services;

(2) "Director", the director of the department of health and senior services or the director's duly authorized representative;

(3) "Passenger", an individual needing transportation in a supine position who does not require medical monitoring, observation, aid, care or treatment during transportation, with the exception of self-administered oxygen as ordered by a physician during transportation;

(4) "Patient", an individual who is sick, injured, wounded, diseased, or otherwise incapacitated or helpless, and who may require medical monitoring, medical observation, aid, care or treatment during transportation, with the exception of self-administered oxygen as ordered by a physician;

(5) "Person", any individual, firm, partnership, copartnership, joint venture, association, cooperative organization, corporation, municipal or private, and whether organized for profit or not, state, county, political subdivision, state department, commission, board, bureau or fraternal organization, estate, public trust, business or common law trust, receiver, assignee for the benefit of creditors, trustee or trustee in bankruptcy, or any other service user or provider;

(6) "Stretcher van", any vehicle other than an ambulance designed and equipped to transport passengers in a supine position. No such vehicle shall be used to provide medical services;

(7) "Stretcher van service", any person or agency that provides stretcher van transportation to passengers who are confined to stretchers and whose conditions are such that they do not need and are not likely to need medical attention during transportation.

190.528. 1. No person, either as owner, agent or otherwise, shall furnish, operate, conduct, maintain, advertise, or otherwise be engaged in or profess to be engaged in the business or service of the transportation of passengers by stretcher van upon the streets, alleys, or any public way or place of the state of Missouri unless such person holds a currently valid license from the department for a stretcher van service issued pursuant to the provisions of sections 190.525 to 190.537 notwithstanding any provisions of chapter 390 or 622, RSMo, to the contrary.

2. Nothing shall preclude the enforcement of any laws, ordinances or regulations of any political subdivision authorized to operate a licensed ambulance service that were in effect prior to August 28, 2001.

3. Stretcher van services may transport passengers.

4. A stretcher van shall be staffed by at least two individuals when transporting passengers.

5. The crew of the stretcher van is required to immediately contact the appropriate ground ambulance service if a passenger's condition deteriorates.

6. Stretcher van services shall not transport patients, persons currently admitted to a hospital or persons being transported to a hospital for emergency treatment.

7. The department of health and senior services shall promulgate regulations, including but not limited to adequate insurance, on-board equipment, vehicle staffing, vehicle maintenance, vehicle specifications, vehicle communications, passenger safety and records and reports.

8. The department of health and senior services shall issue service licenses for a period of no more than five years for each service meeting the established rules.

9. Application for a stretcher van license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.525 to 190.537. The application form shall contain such information as the department deems necessary to make a determination as to whether the stretcher van agency meets all the requirements of sections 190.525 to 190.537 and rules promulgated pursuant to sections 190.525 to 190.537. The department shall conduct an inspection of the stretcher van service to verify compliance with the licensure standards of sections 190.525 to 190.537.

10. Upon the sale or transfer of any stretcher van service ownership, the owner of the stretcher van service shall notify the department of the change in ownership within thirty days prior to the sale or transfer. The department shall conduct an inspection of the stretcher van service to verify compliance with the licensure standards of sections 190.525 to 190.537.

11. Ambulance services licensed pursuant to this chapter or any rules promulgated by the department of health and senior services pursuant to this chapter may provide stretcher van and wheel chair transportation services pursuant to sections 190.525 to 190.537.

12. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

190.531. 1. The department may refuse to issue or deny renewal of any license required pursuant to sections 190.525 to 190.537 for failure to comply with the provisions of sections 190.525 to 190.537 or any lawful regulations promulgated by the department to implement the provisions of sections 190.525 to 190.537. The department shall notify the applicant in writing of the reasons for the refusal and shall advise the applicant of his or her right to file a complaint with the administrative hearing commission as provided by chapter 621, RSMo.

2. The department may cause a complaint to be filed with the administrative hearing commission as provided by chapter 621, RSMo, against any holder of any license required by sections 190.525 to 190.537 or any person who has failed to renew or has surrendered his or her license for failure to comply with the provisions of sections 190.525 to 190.537 or any lawful regulations promulgated by the department to implement such sections. Those regulations shall be limited to the following:

(2) Being finally adjudicated and found guilty, or having entered a plea of guilty or nolo contendere, in a criminal prosecution pursuant to the laws of any state or of the United States, for any offense reasonably related to the qualifications, functions or duties of any activity licensed or regulated pursuant to sections 190.525 to 190.537, for any offense an essential element of which is fraud, dishonesty or an act of violence, or for any offense involving moral turpitude, whether or not sentence is imposed;

(3) Use of fraud, deception, misrepresentation or bribery in securing any certificate, permit or license issued pursuant to sections 190.525 to 190.537 or in obtaining permission to take any examination given or required pursuant to sections 190.537 to 190.540;

(4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception or misrepresentation;

(6) Violation of, or assisting or enabling any person to violate, any provision of sections 190.525 to 190.537, or of any lawful rule or regulation adopted by the department pursuant to sections 190.525 to 190.537;

(7) Impersonation of any person holding a license or allowing any person to use his or her license;

(8) Disciplinary action against the holder of a license or other right to practice any activity regulated by sections 190.525 to 190.537 granted by another state, territory, federal agency or country upon grounds for which revocation or suspension is authorized in this state;

(9) For an individual, being finally adjudged insane or incompetent by a court of competent jurisdiction;

(10) Issuance of a license based upon a material mistake of fact;

(11) Violation of any professional trust or confidence;

(12) Use of any advertisement or solicitation which is false, misleading or deceptive to the general public or persons to whom the advertisement or solicitation is primarily directed;

(13) Violation of the drug laws or rules and regulations of this state, any other state or the federal government;

(14) Refusal of any applicant or licensee, to cooperate with the department of health and senior services during any investigation;

(15) Any conduct or practice which is or might be harmful or dangerous to the mental or physical health of a patient or the public;

(16) Repeated negligence in the performance of the functions or duties of any activity licensed by this chapter.

3. After the filing of such complaint, the proceedings shall be conducted in accordance with the provisions of chapter 621, RSMo. Upon a finding by the administrative hearing commission that the grounds, as provided in subsection 2 of this section, for disciplinary action are met, the department may, singly or in combination, censure or place the person named in the complaint on probation on such terms and conditions as the department deems appropriate for a period not to exceed five years, or may suspend, for a period not to exceed three years, or revoke the license.

4. An individual whose license has been revoked shall wait one year from the date of revocation to apply for relicensure. Relicensure shall be at the discretion of the department after compliance with all the requirements of sections 190.525 to 190.537 relative to the licensing of an applicant for the first time.

5. The department may notify the proper licensing authority of any other state in which the person whose license was suspended or revoked was also licensed, of the suspension or revocation.

6. Any person, organization, association or corporation who reports or provides information to the department pursuant to the provisions of sections 190.525 to 190.537 and who does so in good faith and without negligence shall not be subject to an action for civil damages as a result thereof.

7. The department of health and senior services may suspend any license required pursuant to sections 190.525 to 190.537 simultaneously with the filing of the complaint with the administrative hearing commission as set forth in subsection 2 of this section, if the department finds that there is an imminent threat to the public health. The notice of suspension shall include the basis of the suspension and notice of the right to appeal such suspension. The licensee may appeal the decision to suspend the license to the department. The appeal shall be filed within ten days from the date of the filing of the complaint. A hearing shall be conducted by the department within ten days from the date the appeal is filed. The suspension shall continue in effect until the conclusion of the proceedings, including review thereof, unless sooner withdrawn by the department, dissolved by a court of competent jurisdiction or stayed by the administrative hearing commission.

190.534. 1. Any person violating, or failing to comply with, the provisions of sections 190.525 to 190.537 is guilty of a class B misdemeanor.

2. Each day that any violation of, or failure to comply with, sections 190.525 to 190.537 is committed or permitted to continue shall constitute a separate and distinct offense, and shall be punishable as a separate offense pursuant to this section; but the court may, in appropriate cases, stay the cumulation of penalties.

190.537. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created pursuant to the authority of sections 190.525 to 190.537 shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

321.130. 1. A person, to be qualified to serve as a director, shall be a voter of the district at least two years [prior to his] before the election or appointment and be over the age of twenty-five years; except as provided in subsections 2 and 3 of this section. Nominations and declarations of candidacy shall be filed at the headquarters of the fire protection district by paying a ten dollar filing fee and filing a statement under oath that such person possesses the required qualifications.

2. In any fire protection district located in more than one county one of which is a first class county without a charter form of government having a population of more than one hundred ninety-eight thousand and not adjoining any other first class county or located wholly within a first class county as described herein, a resident shall have been a resident of the district for more than one year to be qualified to serve as a director.

3. In any fire protection district located in a county of the third or fourth classification, a person to be qualified to serve as a director shall be over the age of twenty-five years and shall be a voter of the [county in which the] district [is located] for more than two years [prior to his] before the election or appointment, except that for the first board of directors in such district, a person need only be a voter of the [county in which the] district [is located] for one year [prior to his] before the election or appointment.

4. A person desiring to become a candidate for the first board of directors of the proposed district shall pay the sum of five dollars as a filing fee to the treasurer of the county and shall file with the election authority a statement under oath that [he] such person possesses all of the qualifications set out in this chapter for a director of a fire protection district. Thereafter, such candidate shall have [his] the candidate's name placed on the ballot as a candidate for director.

321.552. 1. Except in any county of the first classification with over two hundred thousand inhabitants, the governing body of any ambulance or fire protection district may impose a sales tax in an amount up to one-half of one percent on all retail sales made in such ambulance or fire protection district which are subject to taxation pursuant to the provisions of sections 144.010 to 144.525, RSMo, provided that such sales tax shall be accompanied by a reduction in the district's tax rate as defined in section 137.073, RSMo. The tax authorized by this section shall be in addition to any and all other sales taxes allowed by law, except that no sales tax imposed pursuant to the provisions of this section shall be effective unless the governing body of the ambulance or fire protection district submits to the voters of such ambulance or fire protection district, at a municipal or state general, primary or special election, a proposal to authorize the governing body of the ambulance or fire protection district to impose a tax pursuant to this section.

2. The ballot of submission shall contain, but need not be limited to, the following language:

"Shall ...................... (insert name of ambulance or fire protection district) impose a sales tax of ........... (insert amount up to one-half) of one percent for the purpose of providing revenues for the operation of the ................. (insert name of ambulance or fire protection district) and the total property tax levy on properties in the ....... (insert name of the ambulance or fire protection district) shall be reduced annually by an amount which reduces property tax revenues by an amount equal to fifty percent of the previous year's revenue collected from this sales tax?

Yes No

If you are in favor of the question, place an "X" in the box opposite "Yes". If you are opposed to the question, place an "X" in the box opposite "No"."

3. If a majority of the votes cast on the proposal by the qualified voters voting thereon are in favor of the proposal, then the sales tax authorized in this section shall be in effect and the governing body of the ambulance or fire protection district shall lower the level of its tax rate by an amount which reduces property tax revenues by an amount equal to fifty percent of the amount of sales tax collected in the preceding year. If a majority of the votes cast by the qualified voters voting are opposed to the proposal, then the governing body of the ambulance or fire protection district shall not impose the sales tax authorized in this section unless and until the governing body of such ambulance or fire protection district resubmits a proposal to authorize the governing body of the ambulance or fire protection district to impose the sales tax authorized by this section and such proposal is approved by a majority of the qualified voters voting thereon.

4. All revenue received by a district from the tax authorized pursuant to this section shall be deposited in a special trust fund, and be used solely for the purposes specified in the proposal submitted pursuant to this section for so long as the tax shall remain in effect.

5. All sales taxes collected by the director of revenue pursuant to this section, less one percent for cost of collection which shall be deposited in the state's general revenue fund after payment of premiums for surety bonds as provided in section 32.087, RSMo, shall be deposited in a special trust fund, which is hereby created, to be known as the "Ambulance or Fire Protection District Sales Tax Trust Fund". The moneys in the ambulance or fire protection district sales tax trust fund shall not be deemed to be state funds and shall not be commingled with any funds of the state. The director of revenue shall keep accurate records of the amount of money in the trust and the amount collected in each district imposing a sales tax pursuant to this section, and the records shall be open to inspection by officers of the county and to the public. Not later than the tenth day of each month the director of revenue shall distribute all moneys deposited in the trust fund during the preceding month to the governing body of the district which levied the tax; such funds shall be deposited with the board treasurer of each such district.

6. The director of revenue may authorize the state treasurer to make refunds from the amounts in the trust fund and credit any district for erroneous payments and overpayments made, and may redeem dishonored checks and drafts deposited to the credit of such district. If any district abolishes the tax, the district shall notify the director of revenue of the action at least ninety days prior to the effective date of the repeal and the director of revenue may order retention in the trust fund, for a period of one year, of two percent of the amount collected after receipt of such notice to cover possible refunds or overpayment of the tax and to redeem dishonored checks and drafts deposited to the credit of such accounts. After one year has elapsed after the effective date of abolition of the tax in such district, the director of revenue shall remit the balance in the account to the district and close the account of that district. The director of revenue shall notify each district of each instance of any amount refunded or any check redeemed from receipts due the district.

7. Except as modified in this section, all provisions of sections 32.085 and 32.087, RSMo, shall apply to the tax imposed pursuant to this section.

321.554. 1. When the revenue from the ambulance or fire protection district sales tax is collected for distribution pursuant to section 321.552, the board of the ambulance or fire protection district, after determining its budget for the year pursuant to section 67.010, RSMo, and the rate of levy needed to produce the required revenue and after making any other adjustments to the levy that may be required by any other law, shall reduce the total operating levy of the district in an amount sufficient to decrease the revenue it would have received therefrom by an amount equal to fifty percent of the previous fiscal year's sales tax receipts. Loss of revenue, due to a decrease in the assessed valuation of real property located within the ambulance or fire protection district as a result of general reassessment, and from state-assessed railroad and utility distributable property based upon the previous fiscal year's receipts shall be considered in lowering the rate of levy to comply with this section in the year of general reassessment and in each subsequent year. In the event that in the immediately preceding year the ambulance or fire protection district actually received more or less sales tax revenue than estimated, the ambulance or fire protection district board may adjust its operating levy for the current year to reflect such increase or decrease. The director of revenue shall certify the amount payable from the ambulance or fire protection district sales tax trust fund to the general revenue fund to the state treasurer.

2. Except that, in the first year in which any sales tax is collected pursuant to section 321.552, the collector shall not reduce the tax rate as defined in section 137.073, RSMo.

3. In a year of general reassessment, as defined by section 137.073, RSMo, or assessment maintenance as defined by section 137.115, RSMo, in which an ambulance or fire protection district in reliance upon the information then available to it relating to the total assessed valuation of such ambulance or fire protection district revises its property tax levy pursuant to section 137.073 or 137.115, RSMo, and it is subsequently determined by decisions of the state tax commission or a court pursuant to sections 138.430 to 138.433, RSMo, or due to clerical errors or corrections in the calculation or recordation of assessed valuations that the assessed valuation of such ambulance or fire protection district has been changed, and but for such change the ambulance or fire protection district would have adopted a different levy on the date of its original action, then the ambulance or fire protection district may adjust its levy to an amount to reflect such change in assessed valuation, including, if necessary, a change in the levy reduction required by this section to the amount it would have levied had the correct assessed valuation been known to it on the date of its original action, provided:

(1) The ambulance or fire protection district first levies the maximum levy allowed without a vote of the people by article X, section 11(b) of the constitution; and

(2) The ambulance or fire protection district first adopts the tax rate ceiling otherwise authorized by other laws of this state; and

(3) The levy adjustment or reduction may include a one-time correction to recoup lost revenues the ambulance or fire protection district was entitled to receive during the prior year.

321.556. 1. The governing body of any ambulance or fire protection district, when presented with a petition signed by at least twenty percent of the registered voters in the ambulance or fire protection district that voted in the last gubernatorial election, calling for an election to repeal the tax pursuant to section 321.552, shall submit the question to the voters using the same procedure by which the imposition of the tax was voted. The ballot of submission shall be in substantially the following form:

"Shall .................. (insert name of ambulance or fire protection district) repeal the ........ (insert amount up to one-half) of one percent sales tax now in effect in the .......... (insert name of ambulance or fire protection district) and reestablish the property tax levy in the district to the rate in existence prior to the enactment of the sales tax?

Yes No

If you are in favor of the question, place an "X" in the box opposite "Yes". If you are opposed to the question, place an "X" in the box opposite "No"."

2. If a majority of the votes cast on the proposal by the qualified voters of the district voting thereon are in favor of repeal, that repeal shall become effective December thirty-first of the calendar year in which such repeal was approved.

[190.044. 1. No taxpayer shall be required to pay property taxes for ground ambulance service to both an ambulance district and a fire protection district or two ambulance districts which operate a ground ambulance service, unless reaffirmed and authorized pursuant to this section. In the event that a taxpayer in a third class county is paying taxes to both entities to provide ground ambulance service, any taxpayer residing in the area subject to the double tax may file a petition with the county clerk in which the area, or greatest part thereof, is situated requesting that the double tax be eliminated and that the area only pay a tax to one entity.

2. Upon receipt of such petition, the county clerk shall determine the area taxed by two such entities and place the question before the voters of such area at the next state or municipal election. The petition shall request that the following question be submitted to the voters residing within the geographic limits of the area:

The .................... (description of area) is currently paying a tax to provide ambulance service to the ................... (name of entity created first) and the .................... (name of entity created second).

As a result, choose only one of the following districts to provide ambulance service and taxation:

................... (name of entity created first)

................... (name of entity created second).

3. The entity receiving the most votes shall be declared as the single taxing entity for the area in question. The taxpayers within the area shall thereafter only pay one tax to the single taxing entity following a three-year period, over which the tax rate levied and collected shall be decreased by one-third each year until such tax is no longer levied or collected by the entity not chosen to provide service.

4. All costs incurred by the county clerk as a result of this section, including election costs, shall be paid by the entity not chosen to provide service.

5. The boundaries and service area of the entities providing ambulance service will reflect the change as determined by the election.]

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