SB 587 - Introduced Bill Text

SECOND REGULAR SESSION

SENATE BILL NO. 587

89TH GENERAL ASSEMBLY

INTRODUCED BY SENATOR SCOTT.

Pre-filed December 5, 1997, and 1,000 copies ordered printed.

TERRY L. SPIELER, Secretary.

S2342.02I

AN ACT

To repeal sections 190.060, 190.100, 190.105, 190.110, 190.115, 190.120, 190.125, 190.130, 190.135, 190.140, 190.141, 190.150, 190.155, 190.160, 190.165, 190.171, 190.175, 190.180, 190.190, 190.235, 190.237, 190.239, 190.241, 190.243, 190.245 and 190.247, RSMo 1994, sections 190.145, as both versions appear in RSMo Supp. 1997, and section 190.185, RSMo Supp. 1997, relating to emergency medical services, and to enact in lieu thereof twenty-eight new sections relating to the same subject.

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

Section A. Sections 190.060, 190.100, 190.105, 190.110, 190.115, 190.120, 190.125, 190.130, 190.135, 190.140, 190.141, 190.150, 190.155, 190.160, 190.165, 190.171, 190.175, 190.180, 190.190, 190.235, 190.237, 190.239, 190.241, 190.243, 190.245 and 190.247, RSMo 1994, sections 190.145, as both versions appear in RSMo Supp. 1997, and section 190.185, RSMo Supp. 1997, are repealed and twenty-eight new sections enacted in lieu thereof, to be known as sections 190.060, 190.100, 190.101, 190.102, 190.103, 190.104, 190.105, 190.106, 190.107, 190.108, 190.120, 190.131, 190.133, 190.134, 190.142, 190.160, 190.165, 190.171, 190.175, 190.180, 190.185, 190.191, 190.196, 190.200, 190.205, 190.241, 190.244 and 190.245, to read as follows:

190.060. 1. An ambulance district shall have and exercise the following governmental powers, and all other powers incidental, necessary, convenient or desirable to carry out and effectuate the express powers:

(1) To establish and maintain an ambulance service within its corporate limits, and to acquire for, develop, expand, extend and improve such service;

(2) To acquire land in fee simple, rights in land and easements upon, over or across land and leasehold interests in land and tangible and intangible personal property used or useful for the location, establishment, maintenance, development, expansion, extension or improvement of an ambulance service. The acquisition may be by dedication, purchase, gift, agreement, lease, use or adverse possession;

(3) To operate, maintain and manage the ambulance service, and to make and enter into contracts for the use, operation or management of and to provide rules and regulations for the operation, management or use of the ambulance service;

(4) To fix, charge and collect reasonable fees and compensation for the use of the ambulance service according to the rules and regulations prescribed by the board from time to time;

(5) To borrow money and to issue bonds, notes, certificates, or other evidences of indebtedness for the purpose of accomplishing any of its corporate purposes, subject to compliance with any condition or limitation set forth in sections 190.005 to 190.085 or otherwise provided by the Constitution of the State of Missouri;

(6) To employ or enter into contracts for the employment of any person, firm, or corporation, and for professional services, necessary or desirable for the accomplishment of the objects of the district or the proper administration, management, protection or control of its property;

(7) To maintain the ambulance service for the benefit of the inhabitants of the area comprising the district regardless of race, creed or color, and to adopt such reasonable rules and regulations as may be necessary to render the highest quality of emergency medical care; to exclude from the use of the ambulance service all persons who willfully disregard any of the rules and regulations so established; to extend the privileges and use of the ambulance service to persons residing outside the area of the district upon such terms and conditions as the board of directors prescribes by its rules and regulations; [and]

(8) To provide for health, accident, disability and pension benefits for the salaried members of its organized ambulance district and such other benefits for the members' spouses and minor children, through either, or both, a contributory or noncontributory plan. The type and amount of such benefits shall be determined by the board of directors of the ambulance district within the level of available revenue of the pension program and other available revenue of the district. If an employee contributory plan is adopted, then at least one voting member of the board of trustees shall be a member of the ambulance district elected by the contributing members. The board of trustees shall not be the same as the board of directors[.]; and

(9) To purchase insurance indemnifying the district and its employees, officers, volunteers and directors against liability in rendering services incidental to the furnishing of ambulance services. Purchase of insurance pursuant to this section is not intended to waive sovereign immunity, official immunity or the Missouri public duty doctrine defenses.

2. An ambulance district shall have the authority to promulgate laws, ordinances or regulations related to providing, selecting or contracting for ambulance services to the public. Under no circumstance, however, should laws, ordinances or regulations ever establish standards that are below state standards.

3. If the department receives official written notification by an ambulance district that, following an appropriate hearing on the merits, an ambulance service has been found in violation of any law, ordinance or regulation promulgated by said ambulance district pursuant to subsection 2 of this section, such ambulance service may be subject to licensure action by the department. No provision of this section is intended to limit or supersede an ambulance district's right to enforce any law, ordinance, regulation, franchise, contract or mutual aid agreement.

[2.] 4. The use of any ambulance service of a district shall be subject to the reasonable regulation and control of the district and upon such reasonable terms and conditions as shall be established by its board of directors.

[3.] 5. A regulatory ordinance of a district adopted under any provision of this section may provide for a suspension or revocation of any rights or privileges within the control of the district for a violation of any regulatory ordinance.

[4.] 6. To purchase insurance indemnifying against liability of the district and the driver and attendants of the ambulance or other equipment or supplies or in rendering services incidental to the furnishing of the ambulance service.

[5.] 7. Nothing in this section or in other provisions of sections 190.005 to 190.085 shall be construed to authorize the district or board to establish or enforce any regulation or rule in respect to the operation or maintenance of the ambulance service within its jurisdiction which is in conflict with any federal or state law or regulation applicable to the same subject matter.

190.100. As used in sections 190.100 to [190.190] 190.245, the following words and terms mean:

(1) "Advanced life support" or "(ALS)", an advanced level of care 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 190.100 to 190.245;

[(1)] (2) "Ambulance", any privately or publicly owned [motor vehicle or, on or after January 1, 1988, any aircraft, if such motor vehicle or aircraft] vehicle or craft that is specially designed [or constructed and equipped and is intended to be used for and is maintained or operated for the transportation of patients, including dual-purpose police patrol cars and funeral coaches or hearses which otherwise comply with the provisions of sections 190.100 to 190.190], 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 personnel or 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 [permanently disabled and] who are disabled, handicapped, normally using a wheelchair, or [handicapped persons] otherwise not acutely ill, or emergency vehicles [at] used within airports;

[(2) "Apprentice", any individual who is not a licensed attendant or attendant-driver, but who holds a certificate of apprenticeship issued by the license officer;

(3) "Attendant", a trained and qualified individual responsible for the operation of an ambulance and the care of the patients transported thereby whether or not the attendant also serves as driver;

(4) "Attendant-driver", a person who is qualified as an attendant and a driver;

(5) "Board", the state board of health of Missouri;

(6) "Dual-purpose police patrol car", a vehicle, operated by a police department, which is equipped as an ambulance, even though it is also used for patrol or other police purposes;

(7) "Emergency medical technician", any person who has successfully completed a course of training approved by the health officer and is certified by the health officer in preliminary emergency medical care;

(8) "Health officer", the director of the department of health of the state of Missouri or his duly authorized representative;

(9) "License officer", the director of the department of health of the state of Missouri or his duly authorized representative;

(10) "Local physician medical advisor" or "local physician medical advisory committee",]

(3) "Ambulance service", a person or entity that provides emergency or nonemergency medical transportation and services, or both, in compliance with sections 190.100 to 190.245, and the rules promulgated thereunder;

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

(5) "Basic life support" or "(BLS)", a basic level of care, as provided to the adult and pediatric patient as supported by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.100 to 190.245;

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

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

(8) "Director", the director of the department of health 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 manifested by symptoms of sufficient severity such that a prudent layperson, possessing an average knowledge of health and medicine, would believe that immediate medical care is required;

(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 190.100 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 as an EMT-B or EMT-P by the department;

(16) "Emergency medical technician-basic" or "EMT-B", a person who has successfully completed a course in instruction in basic life support care as prescribed by the department and is licensed by the department in accordance with standards prescribed by sections 190.100 to 190.245 and rules adopted by the department pursuant to sections 190.100 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 190.100 to 190.245 and rules adopted by the department pursuant to sections 190.100 to 190.245;

(18) "Emergency services", health care items and services furnished or required to screen and stabilize an emergency medical condition 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;

(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 190.100 to 190.245 and who provides emergency medical care through employment by or in association with an emergency medical response agency;

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

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

(22) "Medical director", a physician [or group of physicians] licensed pursuant to chapter 334, RSMo, [appointed] designated by the ambulance service or emergency medical response agency and who [meet] meets criteria established by the department [of health. The local physician medical advisor or local physician medical advisory committee shall have the responsibility to monitor prehospital medical care and ensure that prehospital standards of care and protocols are met] by rules promulgated pursuant to sections 190.100 to 190.245;

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

[(11)] (24) "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;

[(12)] (25) "Person", as used in these definitions and elsewhere in sections 190.100 to 190.245, any individual, firm, partnership, copartnership, joint venture, association, cooperative organization, corporation, [company, group of individuals acting together for a common purpose or organization of any kind, including any governmental agency other than the United States or the state of Missouri;

(13) "Mobile emergency medical technician", a licensed attendant who has been specially trained in emergency cardiac and noncardiac care, and who has successfully completed an emergency service training program certified by the health officer as meeting the requirements of sections 190.100 to 190.190.] 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;

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

(27) "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;

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

(29) "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;

(30) "Regional emergency medical services system", an organization of hospitals, map services and personnel approved by the department in a specific geographic area of sufficient size, population and economic diversity, which coordinates emergency care and nonemergency medical transports pursuant to the EMS region plan adopted for the EMS region in which the system is located;

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

(32) "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.

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 shall be subcommittees of the state advisory council on emergency medical services.

3. The council shall have representatives from diverse geographical regions in the state and representation from appropriate areas of expertise in emergency medical services including volunteers, professional organizations involved in emergency medical services, EMTs, paramedics, nurses, firefighters, physicians, ambulance service administrators, hospital administrators and other health care providers skilled in emergency medical services.

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

5. The purpose of the council is to advise and 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.

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 both public and private emergency resources in the region;

(2) Improvement of public and professional education;

(3) Cooperative research endeavors, and development of standards, protocols and policies.

2. The members of the committees shall serve without compensation except that the department of health 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. Appointments will be for four years with individuals serving until reappointed or replaced.

190.103. 1. One physician with expertise in emergency medical services from each of the EMS regions shall be appointed by the department to serve as a regional EMS medical director. The regional EMS directors shall constitute the state EMS medical directors' advisory committee and shall advise the department and their regions' ambulance services on matters relating to medical control and medical direction in accordance with sections 190.100 to 190.245 and rules adopted by the department pursuant to sections 190.100 to 190.245.

2. Each ambulance service, as well as any emergency medical response agency that provides advanced life support services, is required to have a medical director. The medical director shall provide medical direction to the ambulance service or emergency medical response agency that provides advanced life support services.

3. The medical director, in cooperation with the ambulance service or emergency medical response agency administrator, shall have the responsibility and the authority to ensure that the personnel working under their supervision are able to provide care meeting established standards of care with consideration for state and national standards as well as local area needs and resources. The medical director, in cooperation with the ambulance service or emergency response agency administrator, shall establish and develop triage, treatment and transport protocols, which may include authorization for standing orders.

190.104. 1. The department is authorized to establish a program to improve the quality of emergency care for pediatric patients throughout the state and to implement a comprehensive pediatric emergency medical service system in accordance with standards prescribed by sections 190.100 to 190.245 and rules adopted by the department pursuant to sections 190.100 to 190.245.

2. The department is authorized to receive contributions, grants, donations or funds from any entity to be expended for the program authorized pursuant to this section.

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 [he] such person holds a currently valid license from the department for an ambulance issued pursuant to the provisions of sections 190.100 to [190.195] 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 on the streets, alleys, or any public way or place of the state of Missouri unless [it] the ground ambulance is under the immediate supervision and direction of a person who is holding a currently valid [license as an attendant-driver or attendant; except that, nothing in this section shall be construed to mean that a duly licensed registered nurse or a duly licensed physician be required to hold an attendant-driver or attendant license.] emergency medical technician license. Each ambulance service is responsible for assuring that any person driving its ambulance is competent in emergency vehicle operations.

3. No [person, as either owner, agent or otherwise, who holds a currently valid license for an ambulance, shall, incident to his business or service of transporting patients, transport, carry or convey patients in any vehicle other than an ambulance, but no such licenses] license shall be required for an ambulance service, or for the attendant[, attendant-driver, or certificated apprentice] of an ambulance, which:

(1) Is rendering assistance to [licensed ambulances in the case of a major catastrophe or emergency with which the licensed ambulances of that locality are insufficient or unable to cope] a licensed ambulance service in the case of an emergency, major catastrophe or any other unforseen event or series of events which jeopardizes the ability of the 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 [in emergency, unless the driver, attendant and attendant-driver and the person subject to the provisions of sections 190.100 to 190.195 in respect of such ambulance hold currently valid licenses issued pursuant to sections 190.100 to 190.195] as provided in subdivision (1) of this subsection.

4. The issuance of a license under the provisions of sections 190.100 to [190.195] 190.245 shall not be construed so as to authorize any person, firm, corporation, or association to provide ambulance services or to operate any ambulances without a franchise in any county, municipality or political subdivision which has enacted an ordinance making it unlawful to do so.

5. Notwithstanding any law to the contrary, any person or entity that operated a licensed ambulance prior to December 31, 1997, shall have the right to maintain as its ambulance service area, or similar designation, that geographic area which was, prior to December 31, 1997, described as the primary service area for its licensed vehicles, and any subsequent franchise requirements lawfully imposed by a political subdivision shall not limit such an ambulance service's ability to fully operate as it was operating prior to December 31, 1997.

6. A legally enforceable contract to provide emergency ambulance service for a political subdivision shall expand, without further action by the department, the ambulance service area of the ambulance service under contract with the political subdivision to include the political subdivision for the term of the contract. Subsequent termination of the contract shall result in the corresponding reduction of such service area by removing such political subdivision from the ambulance service area of said ambulance service.

7. An ambulance service may not respond to a request for ambulance service that originates outside of said ambulance service's ambulance service area without the express permission of the political subdivision in which the service originates.

[5.] 8. Sections 190.100 to [190.195] 190.245 shall not preclude the adoption of any law, ordinance or regulation not in conflict with this statute by any county, municipality or political subdivision.

[6.] 9. An ambulance service 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.

[7.] 10. Sections 190.100 to [190.195] 190.245 shall not apply to, nor be construed to include, any motor vehicle used by an employer for the transportation of [his] such employer's employees whose illness or injury occurs on private property, and not on a public highway, nor to any person operating such a motor vehicle.

190.106. 1. Any ambulance service may enter into contracts providing for mutual aid services provided by such ambulance service. The contracts that are agreed upon may provide for compensation from the parties and other terms that are agreeable to the parties and may be for an indefinite period as long as they include a minimum of a sixty-day cancellation notice by either party.

2. Any ambulance service may provide assistance outside of its service area to any other ambulance service in the state that requests it, at the time of an emergency, major catastrophe or any other unforseen event or series of events which jeopardizes the ability of the local ambulance service to promptly respond to emergencies.

3. When responding on mutual aid or emergency aid requests, the ambulance service shall be subject to all provisions of law as if it were providing service within its own service area.

4. Mutual aid contracts may be agreed to between ambulance services in the states neighboring Missouri and ambulance services in the state of Missouri in the exact same manner as contracts between ambulance services within the state of Missouri.

190.107. 1. The department shall have the authority and responsibility to license an air ambulance service in accordance with sections 190.100 to 190.245, and in accordance with rules adopted by the department pursuant to sections 190.100 to 190.245, 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) Licensure fees;

(7) Criteria for compliance with licensure requirements.

2. Application for an air ambulance service license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.100 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 190.100 to 190.245 and rules promulgated pursuant to sections 190.100 to 190.245.

190.108. 1. The department shall issue a ground ambulance service license if the applicant meets the requirements established pursuant to sections 190.100 to 190.245 and the rules adopted by the department pursuant to sections 190.100 to 190.245, 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) Licensure fees;

(6) Ambulance service areas;

(7) Records and forms;

(8) Medical control plans;

(9) Medical director qualifications;

(10) Convenience and necessity hearings to establish an ambulance service area for any ambulance service which did not have an ambulance service area prior to December 31, 1997;

(11) Standards for medical communications; and

(12) Memorandums of understanding with emergency medical response agencies that provide advanced life support.

2. Application for a ground ambulance license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.100 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 190.100 to 190.245 and rules promulgated pursuant to sections 190.100 to 190.245.

190.120. 1. No ambulance service license shall be issued [under] pursuant to sections 190.100 to [190.195] 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 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 [by the board] in regulation:

(1) For injury to or death of individuals in accidents resulting from any cause for which the owner of said vehicle would be liable on account of liability imposed on him by law, regardless of whether the ambulance was being driven by the owner or [his] 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, shall be submitted by all licensees required to provide such insurance [under] pursuant to sections 190.100 to [190.195] 190.245. The insurance policy, or proof of the existence of self-insurance of a city not within a county, shall be submitted to the [license officer] director, in such form as [he] the director may specify, for [his] the director's approval prior to the issuance of each ambulance service license.

3. Every insurance policy 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 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 policy, recovered against any person other than the owner, [his] 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 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 [license officer] 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 [ambulances] ambulance service covered by such policy unless covered by another insurance policy in compliance with sections 190.100 to [190.195] 190.245.

190.131. 1. The department shall accredit or certify training entities for first responders, emergency medical dispatchers, emergency medical technicians-basic and emergency medical technicians-paramedic if the applicant meets the requirements established pursuant to sections 190.100 to 190.245 and the rules adopted by the department pursuant to sections 190.100 to 190.245, and fix reasonable application, accreditation and certification fees as are necessary to accomplish this purpose.

2. Such rules promulgated by the department shall set forth the minimum requirements for entrance criteria, training program curricula, instructors, facilities, equipment, medical oversight, record keeping and reporting.

3. Application for training entity accreditation or certification shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.100 to 190.245. The application form shall contain such information as the department deems reasonably necessary to make a determination as to whether the training entity meets all requirements of sections 190.100 to 190.245 and rules promulgated by the department pursuant to sections 190.100 to 190.245.

4. Upon receipt of such application for training entity accreditation or certification, the department shall determine whether the training entity, its instructors, facilities, equipment, curricula and medical oversight meet the requirements of sections 190.100 to 190.245 and rules promulgated pursuant to sections 190.100 to 190.245.

5. Upon finding these requirements satisfied, the department shall issue a training entity accreditation or certification in accordance with rules promulgated pursuant to sections 190.100 to 190.245.

6. Subsequent to the issuance of a training entity accreditation or certification, the department shall carry out a periodic review of the training entity to assure continued compliance with the requirements of sections 190.100 to 190.245 and all rules promulgated pursuant to sections 190.100 to 190.245.

7. No person or entity shall hold itself out or provide training required by section 190.131 without accreditation or certification by the department.

190.133. 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 emergency medical response agency license.

2. The department shall issue a license to any emergency medical response agency which provides advanced life support, for a period of three years, if the applicant meets the requirements established pursuant to sections 190.100 to 190.245 and the rules adopted by the department. The department may promulgate rules relating to the requirements for an emergency medical response agency, including, but not limited to:

(1) Licensure and relicensure;

(2) License fees;

(3) Medical direction;

(4) Records and forms; and

(5) Memorandum of understanding with local ambulance services and other operational procedures.

3. Application for an emergency medical response agency license shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.100 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 response agency meets all the requirements of sections 190.100 to 190.245 and rules promulgated pursuant to sections 190.100 to 190.245.

4. No person or entity shall hold itself out or provide services of an emergency medical response agency unless it is licensed by the department.

190.134. A dispatch agency is required to have a memorandum of understanding with all ambulance services that it dispatches. If a dispatch agency provides prearrival medical instructions, it is required to have a medical director, whose duties include the maintenance of standards and protocol approval.

190.142. 1. 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 190.100 to 190.245 and the rules adopted by the department pursuant to sections 190.100 to 190.245, 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 190.100 to 190.245;

(3) Initial licensure testing requirements;

(4) Continuing education and relicensure requirements; and

(5) Licensure fees.

2. 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 190.100 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 190.100 to 190.245 and rules promulgated pursuant to sections 190.100 to 190.245.

3. 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.

190.160. The renewal of any license shall require conformance with [all the requirements of sections 190.100 to 190.195 as upon original licensing] sections 190.100 to 190.245 and rules adopted by the department pursuant to sections 190.100 to 190.245.

190.165. 1. The [license officer may] department may deny a license or license renewal application, or suspend or revoke a license issued under the provisions of sections 190.100 to [190.195] 190.245 for failure of a licensee to comply with the provisions of sections 190.100 to [190.195] 190.245, or of regulations promulgated hereunder, or of any other applicable laws [or], ordinances or regulations, or [he] the department may place the licensee on probation for any of the same reasons.

2. [The initial or other ambulance, equipment and premises inspection reports of the health officer provided for by the provisions of sections 190.100 to 190.195 shall be prima facie evidence of compliance or noncompliance with, or violation of, the provisions, standards and requirements provided herein, and of the regulations promulgated hereunder, for the licensing of ambulances.] Grounds for taking licensure action include:

(1) Incompetency in the provision of ambulance service;

(2) Gross negligence or repeated negligence in the provision of ambulance service;

(3) Falsifying any application or record required pursuant to sections 190.100 to 190.245;

(4) Conviction of a crime, pursuant to rules adopted by the department; or

(5) Misconduct, fraud, misrepresentation, dishonesty, unethical conduct or unprofessional conduct in the performance of the functions or duties of any person licensed or regulated by this chapter.

3. Upon suspension, revocation or termination of an ambulance service or emergency medical response agency license hereunder, no person shall be permitted to operate [the] such ambulance service or emergency medical response agency, provided an alternate ambulance service or agency is available for the area served by the entity being disciplined. Upon suspension, revocation or termination of an [attendant's or attendant-driver's] EMT-B or EMT-P license, the [attendant or attendant-driver] EMT-B or EMT-P shall cease to [drive or attend an ambulance, and no person shall employ or permit such individual to drive or attend an ambulance] function as an EMT-B or EMT-P.

4. Any license suspended, revoked or terminated under any provision of sections 190.100 to [190.195] 190.245 will be returned to the [license officer] department within ten days of such suspension, revocation or termination.

190.171. Any person aggrieved by an official action of the department of health affecting the licensed status of a person under the provisions of sections 190.100 to [190.195] 190.245, 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 or the department of social services.

190.175. 1. The department shall develop and administer a uniform data collection system on all ambulance runs and injured patients, adopted by rules by the department for the purpose of injury etiology, patient care outcome, establishment of peer review committees as provided in section 537.035, RSMo, injury prevention and research purposes. The department may require health care providers to provide additional data for regional medical peer review for regional quality improvement activities, and is authorized to establish peer review committees as provided in section 537.035, RSMo. The department shall not require disclosure by hospitals of data elements pursuant to this section unless those data elements are required by a federal agency or were submitted to the department as of January 1, 1998, pursuant to:

(1) Departmental regulation of trauma centers; or

(2) The Missouri head and spinal cord injury registry established by sections 192.735 to 192.745, RSMo; or

(3) Abstracts of inpatient hospital data.

2. Emergency medical dispatchers, emergency medical technicians, first responders and emergency medical technicians-paramedics shall be considered to be "health care professionals" as defined in section 537.035, RSMo, only for the purposes of section 537.035, RSMo, and shall be subject to the provisions and limitations of section 537.035, RSMo.

190.180. 1. Any person violating, or failing to comply with, the provisions of sections 190.100 to [190.195] 190.245 is guilty of a misdemeanor and, upon conviction thereof, shall be fined an amount not exceeding one thousand dollars or imprisonment for a period not exceeding thirty days, or by both such fine and imprisonment, for each offense.

2. Each day that any violation of, or failure to comply with, sections 190.100 to [190.195] 190.245 is committed or permitted to continue shall constitute a separate and distinct offense and shall be punishable as such hereunder; but the court may, in appropriate cases, stay the cumulation of penalties.

3. The attorney general of Missouri shall have concurrent jurisdiction with any and all prosecuting attorneys to prosecute persons in violation of sections 190.100 to [190.195] 190.245, and the attorney general or prosecuting attorney may institute injunctive proceedings against any person operating an ambulance service in violation of sections 190.100 to [190.195] 190.245.

190.185. The [state board of health of Missouri] department shall adopt, amend, promulgate, and enforce such rules, regulations and standards with respect to [all ambulances, ambulance service, attendant mobile emergency medical technicians, attendant-drivers and certificated apprentices to be licensed under the provisions of sections 190.093 to 190.249, and all emergency medical technicians to be certified under the provisions of sections 190.093 to 190.249,] the provisions of this chapter as may be designed to further the accomplishment of the purpose of this law in promoting [safe and adequate ambulance] 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 rule or portion of a rule promulgated [under] pursuant to the authority of sections 190.093 to [190.249] 190.245 shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

190.191. 1. All ground ambulance vehicles and air ambulance aircraft that have or are qualified to have a valid license issued by the department on the day that sections 190.100 to 190.245 take effect will have their ambulance vehicle or aircraft license expiration date extended to a date that is one year after the effective date of sections 190.100 to 190.245.

2. All air ambulance services and ground ambulance services shall have until one year after the effective date of rules developed pursuant to sections 190.100 to 190.245 to comply with rules developed pursuant to sections 190.100 to 190.245. Pursuant to sections 190.100 to 190.245, the department may adjust the initial period of licensure of any air ambulance service or ground ambulance service licensed pursuant to sections 190.100 to 190.245 from one year to five years to equalize the number of licenses that may be renewed during each year of any five-year licensure period.

3. License fees shall be prorated for any air or ground ambulance service license issued by the department with an adjusted license period.

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 190.100 to 190.245, or by rules adopted pursuant to sections 190.100 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 shall cooperate with the department's efforts to monitor and enforce compliance by those individuals subject to the requirements of sections 190.100 to 190.245.

190.200. The department of health in cooperation with local and regional EMS systems and agencies may provide public and professional information and education programs related to emergency medical services systems including trauma systems and emergency medical care and treatment. The department of health may also provide public information and education programs for informing residents of and visitors to the state of the availability and proper use of emergency medical services, of the value and nature of programs to involve citizens in the administering of prehospital emergency care, including cardiopulmonary-resuscitation, and of the availability of training programs in emergency care for members of the general public.

190.205. 1. Health insurance carriers and managed care plans shall not prohibit or discourage the use of the 911 system when emergency services are needed.

2. A health carrier shall cover emergency services necessary to screen and stabilize an enrollee and shall not require prior authorization of such services.

3. If a request for emergency services is made to an ambulance service which is not the 911 provider or the recognized emergency provider in areas not covered by 911 ambulance services, then the 911 provider or the recognized emergency provider shall be notified immediately by the ambulance service receiving the request. Agencies will consider a joint response in order to ensure a rapid response, appropriate level of care and transport to an appropriate receiving hospital.

4. Coverage of emergency services shall be subject to applicable copayments, coinsurance and deductibles.

5. When an enrollee receives an emergency service that requires immediate postevaluation or poststabilization services, a health carrier shall provide an authorization decision within sixty minutes of receiving a request; if the authorization decision is not made within sixty minutes, such services shall be deemed approved.

6. No retrospective denial shall occur for services delivered as a result of receiving authorization to provide evaluation and treatment from an insurance carrier or managed care plan's representative or the patient's primary care physician.

190.241. 1. The department shall designate a hospital as [a] an adult, pediatric or adult and pediatric trauma center when a hospital, upon proper application submitted by the hospital and site review, has been found by the department to meet the applicable level of trauma center criteria for designation in accordance with rules adopted by the department.

2. The department shall, not less than once every five years, conduct an on-site review of every trauma center through appropriate department personnel or a qualified contractor. No person shall be a qualified contractor for purposes of this subsection who has a substantial conflict of interest in the operation of any trauma center [already existing in this state] under review. The department may deny, place on probation, suspend or revoke a trauma center designation in any case in which it has reasonable cause to believe that there has been a substantial failure to comply with the provisions of [sections 190.235 to 190.249] this chapter or any rules or regulations promulgated [under the provisions of sections 190.235 to 190.249] pursuant to this chapter. If the department of health has reasonable cause to believe that a hospital is not in compliance with such provisions or regulations, it may conduct additional announced or unannounced site reviews of the hospital to verify compliance. If a trauma center fails two consecutive on-site reviews because of substantial noncompliance with standards prescribed by sections 190.100 to 190.245 or rules adopted by the department pursuant to sections 190.100 to 190.245, its trauma center designation shall be revoked.

3. The department may establish appropriate fees to offset [some of] the costs of [reverification of trauma centers if the department has reasonable cause to believe that such verification is necessary] trauma center reviews.

4. Any person aggrieved by an action of the department of health affecting the trauma center designation [under the provisions of sections 190.235 to 190.249] pursuant to this chapter, including the revocation, the suspension, or the granting of, refusal to grant, or failure to renew a designation, may seek a determination thereon by the administrative hearing commission pursuant to the provisions of [section 621.045] chapter 536, RSMo. [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.] No person shall hold itself out to the public as an adult, pediatric or adult and pediatric trauma center unless it is designated as such by the department of health.

190.244. 1. Severely injured patients shall be transported to a trauma center. When initial transport from the scene of injury to a trauma center would be prolonged, the severely injured patient may be transported to the nearest appropriate facility for stabilization prior to transport to a trauma center.

2. Transport of the severely injured patient shall be governed by the principles of timely and medically appropriate care; consideration of reimbursement mechanisms shall not supersede those principles.

3. Patients who are not severely injured shall be transported to and cared for at the hospital of their choice so long as such ambulance service is not in violation of local protocols.

190.245. The department shall require hospitals, as defined by chapter 197, RSMo, designated as trauma centers to provide for a peer review system, approved by the department, for trauma cases pursuant to the provisions of section 537.035, RSMo. For purposes of sections [190.235 to 190.249] 190.100 to 190.245, the department of health shall have the same powers and authority of a health care licensing board pursuant to subsection 6 of section 537.035, RSMo. Failure of a hospital to provide all medical records necessary for the department to implement provisions of sections [190.235 to 190.249] 190.100 to 190.245 shall result in the revocation of the hospital's designation as a trauma center. Any medical records obtained by the department or peer review committees shall be used only for purposes of implementing the provisions of sections [190.235 to 190.249] 190.100 to 190.245 and the names of hospitals, physicians and patients shall not be released by the department or members of review committees.

[190.110. 1. An application for an ambulance license shall be made upon such forms as may be prepared or prescribed by the license officer and shall contain:

(1) The name and address of the applicant and of the owner of the ambulance;

(2) The trade or other fictitious name, if any, under which the applicant does business and proposes to do business;

(3) The training and experience of the applicant in the transportation and care of patients;

(4) A description of each ambulance, including the make, model, year of manufacture, motor and chassis number or other distinguishing number; current state license number; the length of time the ambulance has been in use; and the color scheme, insignia, name, monogram or other distinguishing characteristics to be used to designate applicant's ambulance;

(5) The location and description of the place from which it is intended to operate;

(6) Such other information as the license officer shall deem reasonably necessary to a fair determination of compliance with sections 190.100 to 190.195.

2. An annual license fee of twenty dollars shall accompany each application for each ambulance, but no fee will be required for an ambulance owned or operated by a political subdivision of the state.][190.115. 1. Each ambulance shall, at all times when in use as such:

(1) Be suitable for the transportation of patients from the standpoint of health, sanitation and safety, and be maintained in suitable premises;

(2) Contain equipment conforming with the standards, requirements and regulations provided for herein, which equipment shall be in proper and good condition for such use;

(3) Currently comply with all applicable laws and local ordinances relating to health, sanitation and safety;

(4) Be equipped with such lights, sirens and special markings to designate it as an ambulance as may be prescribed in reasonable regulations promulgated by the board;

(5) Be equipped with approved safety belts for the driver, and for a passenger in the front seat if such seat is provided;

(6) Be equipped with an approved safety belt for the attendant in the patient compartment and an approved restraining device for the litter and patient; and

(7) Be covered by an insurance policy in conformance with section 190.120.

2. Any change of ownership of a licensed ambulance shall terminate the license and shall require a new application and a new license and conformance with all the requirements of sections 190.100 to 190.195 as upon original licensing.

3. Application for transfer of any ambulance license to another or substitute vehicle shall require conformance with all the requirements of sections 190.100 to 190.195 as upon original licensing and approval of the licensing officer. No ambulance license may be sold, assigned, mortgaged or otherwise transferred without prior approval of the license officer and a finding by him of conformance with all the requirements of sections 190.100 to 190.195 as upon original licensing.

4. Each licensed ambulance, its equipment and the premises designated in the application and all records relating to its maintenance and operation as such, shall be open to inspection by the health officer or his designated representative during usual hours of operation.

5. No official entry made upon a license may be defaced, removed or obliterated.][190.125. 1. The license officer shall, upon receipt of an application for an ambulance license as provided for by the provisions of sections 190.100 to 190.195, cause such investigation as he deems necessary to be made of the applicant and of his proposed operations.

2. The license officer shall issue a license hereunder for a specified ambulance, to be valid for a period of one year, unless suspended, revoked or terminated, when he finds, upon proper notice and hearing:

(1) That the public convenience and necessity require the proposed ambulance service;

(2) That each ambulance, its required equipment and the premises designated in the application, have been certified by the health officer as provided herein;

(3) That the applicant is a responsible person who bears a good reputation for honesty, integrity, fair dealing, and is competent to operate an ambulance service;

(4) That the ambulance will be operated only by duly licensed attendants, attendant-drivers, and certificated apprentices;

(5) That all the requirements of sections 190.100 to 190.195 and all other applicable laws and ordinances have been met.

3. Prior to the issuance of any ambulance license hereunder, the license officer shall cause an inspection to be made of the vehicles, equipment and premises designated in each application hereunder, and shall certify his approval in a written report when he finds compliance with the standards prescribed in subdivision (1) of section 190.115, section 190.120 and in section 190.130, and with the regulations promulgated under such sections; but the license officer shall have no responsibility, and shall exercise no authority in connection with laws and ordinances of general applicability which deal with motor vehicle inspection.

4. Subsequent to the issuance of an ambulance license under the provisions of sections 190.100 to 190.195, the license officer shall cause a periodic inspection to be made of each licensed vehicle, and its equipment and premises, whenever he deems such inspection to be necessary, and shall promptly file a written report of his findings with the department of health. The periodic inspection hereunder shall be in addition to any other safety or motor vehicle inspection required to be made for ambulances or other motor vehicles, or other inspections required to be made, under general law or ordinances, and shall not excuse compliance with any requirement of law or ordinance to display any official certificate of motor vehicle inspection and approval nor excuse compliance with the requirements of any other applicable general law or ordinance.

5. A copy of each ambulance, equipment and premises inspection report submitted by the license officer under the provisions of this section shall be promptly transmitted to the applicant or licensee to whom it refers.

6. The license officer may change periods to equalize work:

(1) Whenever he shall determine from an increase or decrease in the number of ambulance licenses in any given month, that the volume of clerical work and inspections of licensing of ambulances in such month has become so disproportionate to the volume of work in the remaining months, he is authorized and empowered to change the license period of such number of ambulances as may be necessary to increase or reduce the volume of licenses in one or more months by advancing the renewal date and shortening the license period of such ambulances.

(2) Such shifting of license months shall be accomplished by notifying the licensees of the change, giving them credit for the portion of the license period not yet elapsed. In such instances the license officer shall assign and issue a new license for the ambulance designating the new license expiration date.][190.130. Each licensee of an ambulance shall comply with such reasonable regulations as may be promulgated by the board and shall maintain in each such ambulance, at all times when it is in use as an ambulance, all equipment required in regulations promulgated by the board. In promulgating equipment regulations, the board shall take into consideration the current list of essential equipment for ambulances adopted by the American College of Surgeons.][190.135. 1. Applications for attendants', mobile emergency medical technicians' and attendant-drivers' licenses shall be made upon forms prescribed by the license officer and shall contain:

(1) The applicant's full name, current address and the addresses of all places of residence for two years previous to moving to his present address;

(2) The applicant's age, height, weight, color of eyes and hair;

(3) The applicant's current operator's or chauffeur's license number;

(4) Whether his operator's or chauffeur's license has ever been suspended or revoked, and if so, when and where and for what cause;

(5) Whether he has ever been convicted of a felony or misdemeanor, and if so, when and where and for what cause;

(6) Whether he has ever been convicted for driving while intoxicated, and if so, when and where;

(7) Whether he has ever been convicted for any moving motor vehicle violation, and if so, when and where and for what cause;

(8) The applicant's training and experience in the transportation and care of patients, and whether he has previously been licensed as a chauffeur, attendant or attendant-driver, and if so, when and where, and whether his license has ever been revoked or suspended in any jurisdiction and for what cause;

(9) Two recent photographs of the applicant, of a size designated by the license officer, one of which shall be attached by the license officer to the license;

(10) Such other information as the license officer shall deem reasonably necessary to a fair determination of compliance with sections 190.100 to 190.195.

2. Each application shall be accompanied by a license fee of three dollars, but no fee will be required for applicants who are employed for such duties by the state or a political subdivision of this state.][190.140. Notwithstanding any other provision of sections 190.100 to 190.190, mobile emergency medical technicians may do any of the following at the scene of the accident in an ambulance or at the emergency room of a licensed hospital:

(1) Render rescue, first-aid and resuscitation services;

(2) Perform cardiopulmonary resuscitation and defibrillation in a pulseless, nonbreathing patient, and:

(a) For the cardiac arrest patient, the mobile emergency medical technician may initiate advanced cardiac life support procedures such as endotracheal intubation, initiation of intravenous lines, and administration of initial medications, according to current nationally acceptable emergency cardiac guidelines when approved by the department of health and the local physician medical advisor or local physician medical advisory committee;

(b) For the patient with severe, multisystem trauma or with compromised vital signs the mobile emergency medical technician may establish airway, apply and inflate the PAST garment, initiate intravenous therapy or administer initial medications according to protocols which have been approved by the department of health and the local physician medical advisor or local physician medical advisory committee;

(c) Notwithstanding the provisions of subdivision (4) of this section, procedures may be initiated pursuant to paragraphs (a) and (b) of this subdivision prior to any radio or telephone contact with a physician or registered nurse. After initiating procedures pursuant to paragraphs (a) and (b) of this subdivision, the mobile emergency medical technician shall immediately make radio or telephone contact with a physician or registered nurse designated by a physician;

(3) During training at the hospital and while caring for patients in the hospital administer parenteral medications under the direct supervision of a physician or a registered nurse; and

(4) Where voice contact or a telemetered electrocardiogram is monitored by a physician or a registered nurse authorized by a physician, and direct communication is maintained, mobile emergency medical technicians may upon order of such licensed physician or such licensed registered nurse do any of the following:

(a) Administer intravenous saline or glucose solutions;

(b) Perform gastric suction by intubation;

(d) Administer parenteral injections of any of the following classes of drugs:

a. Antiarrhythmic agents;

b. Vagolytic agents;

c. Chronotropic agents;

d. Analgesic agents;

e. Alkalinizing agents;

f. Vasopressor agents; and

g. Other drugs which may be deemed necessary by such ordering physician;

(5) Deliver emergency medical care to the sick and injured while in the emergency department of a licensed hospital and until care responsibility is assumed by a licensed physician or a licensed registered nurse.][190.141. 1. Notwithstanding any other provisions of sections 190.100 to 190.190, emergency medical technicians may perform any of the following at the scene of an emergency or in an ambulance:

(1) Patient assessment and vital signs;

(2) Airway maintenance to include use of:

(a) Oropharyngeal and nasopharyngeal airways;

(b) Esophageal obturator airways with or without gastric suction device; and

(3) Oxygen therapy;

(4) Oropharyngeal suctioning;

(5) Cardiopulmonary resuscitation procedures;

(6) Control accessible bleeding;

(7) Application of pneumatic anti-shock garment;

(8) Management of outpatient medical emergencies;

(9) Extrication of patients and lifting and moving techniques;

(10) Management of musculoskeletal and soft tissue injuries to include dressing and bandaging wounds or the splinting of fractures, dislocations, sprains or strains and rendering first aid services;

(11) Use of backboards to immobilize the spine;

(12) Defibrillate a pulseless patient under the following conditions:

(a) Perform, when approved by the local physician medical advisor or local physician medical advisory committee and where voice contact by radio or telephone is monitored by a person licensed to practice medicine or a registered nurse, where authorized by a person licensed to practice medicine, and direct communication is maintained, upon order of such person or such nurse, defibrillation with an automatic external defibrillator with data recording capabilities; or

(b) Perform, during an emergency, that activity specified in paragraph (a) of this subsection, before contacting the person licensed to practice medicine and surgery or authorized registered nurse when specifically authorized to perform such activities by written protocols approved by the local physician medical advisory or local physician medical advisory committee and the department of health.

2. An employer of the paid or volunteer emergency medical technician shall have the same physician medical advisor or local physician advisory committee as the local licensed ambulance service, to review, approve and monitor the activities which include but are not limited to recordkeeping, equipment maintenance, quality assurance and operation standards of the emergency medical technician.][190.145. 1. The license officer shall, within a reasonable time after receipt of an application, cause such investigation as he deems necessary to be made of the applicant for an attendant's or attendant-driver's license. The director of the department of health may authorize investigations into criminal and driving records in other states for any applicant.

2. The license officer shall issue a license to an attendant or attendant-driver, valid for a period of three years, unless earlier suspended, revoked or terminated, when he finds that the applicant:

(1) Is eighteen years of age or older;

(2) Is not addicted to the use of intoxicating liquors or narcotics, and is morally fit for the position;

(3) Is able to speak, read and write the English language;

(4) Has been found by a duly licensed physician, upon examination attested to on a form provided by the health officer, to be of sound physique, possessing visual acuity conforming to that required for a chauffeur's license, and free of physical defects or diseases which might impair the ability to drive or attend an ambulance;

(5) For each applicant for attendant or attendant-driver's license, that such applicant has a currently valid certificate evidencing successful completion of a course of training equivalent to the advanced course in first aid given by the American Red Cross or the United States Bureau of Mines, or incorporating the curriculum of the basic training for ambulance personnel recommended by the United States Department of Transportation. No one shall be licensed as an attendant-driver unless he holds a currently valid motor vehicle operator's license from the state of Missouri or another state; and

(6) For each applicant for a mobile emergency medical technician's license, that such applicant meets the requirements for attendant, of this subsection, and in addition has successfully completed an emergency service training program consisting of a minimum of two hundred hours of training including, but not limited to, didactic and clinical experience in a cardiac care unit and in an emergency vehicle unit.

3. A license as attendant mobile emergency medical technician or attendant-driver is not assignable or transferable.

4. No official entry made upon a license may be defaced, removed or obliterated.][190.145. 1. The license officer shall, within a reasonable time after receipt of an application, cause such investigation as he deems necessary to be made of the applicant for an attendant's or attendant-driver's license. The director of the department of health may authorize investigations into criminal and driving records in other states for any applicant.

2. The license officer shall issue a license to an attendant or attendant-driver, valid for a period of three years, unless earlier suspended, revoked or terminated, when he finds that the applicant:

(1) Is eighteen years of age or older;

(2) Is not addicted to the use of intoxicating liquors or narcotics, and is morally fit for the position;

(3) Is able to speak, read and write the English language;

(5) For each applicant applying for relicensure for an attendant or attendant-driver's license, that such applicant has a currently valid certificate evidencing successful completion of a course of training, as presently defined by the state board of health through its rules and regulations in accordance with section 190.185 and chapter 536, RSMo. For each applicant applying for initial licensure for an attendant or attendant-driver's license, that such applicant has a currently valid certificate evidencing successful completion of a course of training as presently defined by the state board of health through its rules and regulations in accordance with section 190.185 and chapter 536, RSMo, which incorporates the curriculum of the EMT-basic training for ambulance personnel recommended by the United States Department of Transportation. No one shall be licensed as an attendant-driver unless he holds a currently valid motor vehicle operator's license from the state of Missouri or another state; and

(6) For each applicant applying for relicensure for a mobile emergency medical technician's license, that such applicant meets the requirements for attendant, subdivisions (1) to (5) of this subsection, and in addition has a currently valid certificate evidencing successful completion of a course of training, as presently defined by the state board of health through its rules and regulations in accordance with section 190.185 and chapter 536, RSMo. For each applicant applying for initial licensure for a mobile emergency medical technician's license, that such applicant has a currently valid certificate evidencing successful completion of a course of training as presently defined by the state board of health through its rules and regulations in accordance with section 190.185 and chapter 536, RSMo, which incorporates the curriculum of the EMT-paramedic training for ambulance personnel recommended by the United States Department of Transportation.

3. A license as attendant mobile emergency medical technician or attendant-driver is not assignable or transferable.

4. No official entry made upon a license may be defaced, removed or obliterated.

5. Notwithstanding anything herein to the contrary, ground ambulance services located in a city not within a county may maintain their ambulance service areas, and nothing in this section shall authorize the limitation or other restriction of the ambulance service area of ground ambulance services located in a city not within a county.][190.150. 1. An application for a certificate of apprenticeship shall be made upon such forms as may be prepared or prescribed by the license officer and shall contain:

(1) The applicant's full name, current residence and the addresses of all places of residence for two years previous to his present address;

(2) The applicant's age, height, weight, color of eyes and hair;

(3) The applicant's current operator's or chauffeur's license number;

(4) Whether his operator's or chauffeur's license has ever been suspended or revoked, and if so, when and where and for what cause;

(5) Whether he has ever been convicted of a felony or misdemeanor, and if so, when and where and for what cause;

(6) Whether he has ever been convicted of driving while intoxicated, and if so, when and where;

(7) Whether he has ever been convicted of any moving motor vehicle violation, and if so, when and where and for what cause;

(8) The applicant's training and experience in the transportation and care of patients, and whether he has previously been licensed as a chauffeur, attendant, or attendant-driver, and if so, when and where, and whether his license has ever been revoked or suspended in any jurisdiction and for what cause;

(9) A description of the apprenticeship in which the applicant is currently engaged, or which is proposed, including a detailed description of the training which the applicant will receive, the location of the training, the names and qualifications of all instructors or supervising personnel, and the approximate length of the apprenticeship;

(10) Two recent photographs of the applicant, of a size designated by the license officer, one of which shall be attached by the license officer to the certificate of apprenticeship;

(11) Such other information as the licensing officer shall deem reasonably necessary to be a fair determination of compliance with sections 190.100 to 190.195.

2. Each application shall be accompanied by a certificate fee of three dollars, but no fee will be required for applicants who are employed for such duties by the state or a political subdivision of the state.][190.155. 1. The license officer shall, within a reasonable time after receipt of an application, cause such investigation as he deems necessary to be made of the applicant for a certificate of apprenticeship.

2. The license officer shall issue a certificate of apprenticeship, for not more than one year, unless earlier suspended, revoked or terminated, when he finds that the applicant:

(1) Is eighteen years of age or older;

(2) Is not addicted to the use of intoxicating liquors or narcotics, and is morally fit for the position;

(3) Is able to speak, read and write the English language;

(4) Has been found by a duly licensed physician, upon examination attested to on a form provided by the health officer, to be of sound physique, and free of physical defects or diseases which might impair the ability to attend an ambulance; and

(5) Is engaged in or proposes to be engaged in a course of training, the successful completion of which will be equivalent to completion of an advanced course in first aid given by the American Red Cross or the United States Bureau of Mines.][190.175. 1. Each licensee of an ambulance shall maintain accurate records, which contain the following information concerning the transportation of each patient within the state of Missouri, from one place herein to another place within or beyond its limits:

(1) Each ambulance licensee will maintain a daily log to contain such data as the license officer may prescribe on each and every ambulance run which he or a duly authorized agent accepts;

(2) The entries will be consecutive, with no blank spaces or blank paper. Records will be retained by the ambulance licensee for five years, readily available for inspection by the license officer, notwithstanding transfer, sale or discontinuance of the ambulance services or business;

(3) Trip tickets for each ambulance run on which are entered pertinent remarks by the ambulance attendant, or attendant-driver, signed instructions of the physician requesting special service, official receipt for patient at destination, and such other items as the license officer may prescribe.

2. Such records shall be available for inspection by the health officer at any reasonable time during business hours.][190.190. Any ambulance, attendant or attendant-driver which is engaged in the business or service of the transportation of patients at the time of the promulgation of any applicable rule or regulation or minimum standard under this law shall be given a reasonable time under the particular circumstances, not to exceed six months from the date of such promulgation, within which to comply with such rules and regulations and minimum standards.][190.235. As used in sections 190.235 to 190.249, the following terms mean:

(1) "Application", a request for trauma center designation or reverification on forms developed by the department of health;

(2) "Applicant", a hospital which has submitted an application and fee when applicable to the department of health for trauma center designation or reverification;

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

(4) "Department", the Missouri department of health;

(5) "Director", the director of the department of health or his designee;

(6) "Emergency medical services 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 which occur either as a result of medical emergency or of an accident, natural disaster or similar situation;

(7) "Hospital", a medical facility which is subject to provisions of chapter 197, RSMo, or a hospital operated by the state;

(8) "Local physician medical advisor" or "local physician medical advisory committee", a physician or group of physicians licensed pursuant to chapter 334, RSMo, appointed by the ambulance service and who meet criteria established by the department of health. The local physician medical advisor or local physician medical advisory committee shall have the responsibility to monitor prehospital medical care and ensure that prehospital standards of care and protocols are met;

(9) "Trauma center", a hospital that has been designated by the Missouri department of health upon proper application and site review as being capable of providing level I, II, or III systematized medical and nursing care for the trauma patient.][190.237. 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.

2. 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, emergency medical technicians, EMT-paramedics, registered nurses, firefighters, physicians, hospital administrators, and other health care providers concerned with emergency medical services.

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

4. 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 service system. The council shall advise the governor, the general assembly, and the department on at least the following aspects of the emergency medical service system: public information, telephone access systems, central dispatch centers, and appropriate telecommunications equipment, purchases of ambulances and equipment, treatment, triage and transfer protocols, appropriate training standards for prehospital and inhospital emergency medical service personnel, licensing standards for ground ambulance vehicles, appropriate standards for air ambulances, and a voluntary management training program.][190.239. 1. The department shall promulgate rules and regulations in regard to trauma center designation. When making such rules and regulations, the department shall consider the recommendations of the state advisory council on emergency medical services. No hospital shall hold itself out to the public as a trauma center unless designated by the department of health. Any hospital which meets the criteria for designation as a trauma center shall be so designated, upon proper application to the department.

2. The department shall promulgate rules and regulations on trauma triage and transfer protocols to ensure that trauma patients receive the most appropriate level of care in the most timely fashion. When making such rules and regulations, the department shall consider the recommendations of the state advisory council on emergency medical services.][190.243. 1. A physician or registered nurse authorized by a physician who has established verbal communication with ambulance personnel shall instruct the ambulance personnel to transport a severely injured patient to the closest hospital or designated trauma center, as determined according to estimated transport time whether by ground ambulance or air ambulance, in accordance with transport protocol approved by the local physician medical advisor or local physician medical advisory committee and the department of health, even when the hospital is located outside of the ambulance service's primary service area.

2. Patients who are not severely injured shall be transported to and cared for at the hospital of their choice, so long as such ambulance service is not in violation of local ordinances.][190.247. The department may purchase ambulances and associated equipment for governmental ambulance agencies within the limits of appropriations made for that purpose, not to exceed one-half the cost of the ambulance or equipment.]

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