SECOND REGULAR SESSION

[PERFECTED]

HOUSE SUBSTITUTE NO. 2 FOR

HOUSE COMMITTEE SUBSTITUTE FOR

HOUSE BILL NO. 1186

88TH GENERAL ASSEMBLY

Taken up for Perfection April 17, 1996. House Substitute No. 2 for House Committee Substitute for House Bill No. 1186 ordered Perfected and printed, as amended.

DOUGLAS W. BURNETT, Chief Clerk

L2969.12P

AN ACT

To repeal sections 190.015, 190.043, 190.055, 190.060, 190.073, 190.093, 190.095, 190.100, 190.105, 190.110, 190.115, 190.120, 190.125, 190.130, 190.135, 190.140, 190.141, 190.145, 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, 190.247, 354.400 and 354.535, RSMo 1994, and section 190.185, RSMo Supp. 1995, relating to emergency services, and to enact in lieu thereof thirty-one new sections relating to the same subject.

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

Section A. Sections 190.015, 190.043, 190.055, 190.060, 190.073, 190.093, 190.095, 190.100, 190.105, 190.110, 190.115, 190.120, 190.125, 190.130, 190.135, 190.140, 190.141, 190.145, 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190.239, 190.241, 190.243, 190.245, 190.247, 354.400 and 354.535, RSMo 1994, and section 190.185, RSMo Supp. 1995, are repealed and thirty-one new sections enacted in lieu thereof, to be known as sections 190.001, 190.015, 190.043, 190.055, 190.060, 190.100, 190.101, 190.102, 190.103, 190.104, 190.105, 190.107, 190.108, 190.113, 190.131, 190.133, 190.142, 190.171, 190.175, 190.180, 190.181, 190.185, 190.190, 190.196, 190.200, 190.205, 190.241, 190.243, 354.400, 354.535 and 1, to read as follows:

190.001. Sections 190.001 to 190.250 shall be known and may be cited as the "Comprehensive Emergency Medical Services Systems Act".

190.015. Whenever the creation of an ambulance district is desired, a number of voters residing in the proposed district equal to ten percent of the vote cast for governor in the proposed district in the next preceding gubernatorial election may file with the county clerk in which the territory or the greater part thereof is situated a petition requesting the creation thereof. In case the proposed district which shall be contiguous is situated in two or more counties, the petition shall be filed in the office of the county clerk of the county in which the greater part of the area is situated, and the commissioners of the county commission of the county shall set the petition for public hearing. The petition shall set forth:

(1) A description of the territory to be embraced in the proposed district;

(2) The names of the municipalities located within the area;

(3) The name of the proposed district;

(4) The population of the district which shall not be less than two thousand inhabitants;

(5) The assessed valuation of the area, which shall not be less than [two] ten million [five hundred thousand] dollars; and

(6) A request that the question be submitted to the voters residing within the limits of the proposed ambulance district whether they will establish an ambulance district [under] pursuant to the provisions of sections 190.005 to 190.085 to be known as ".......... Ambulance District" for the purpose of establishing and maintaining an ambulance service.

190.043. Subject to the provisions of chapter 137, RSMo, in addition to the tax rate increase allowed pursuant to subdivision [(6)] (3) of subsection 5 of section 137.073, RSMo, if an ambulance district voluntarily decreases its tax rate duly authorized [under] pursuant to section 190.040 or 190.041 in any tax year, such ambulance district may in any subsequent tax year increase such tax rate, without voter approval, to the rate previously authorized [under] pursuant to section 190.040 or 190.041.

190.055. 1. The board of directors of a district shall possess and exercise all of its legislative and executive powers. Within thirty days after the election of the initial directors, the board shall meet. The time and place of the first meeting of the board shall be designated by the county commission. At its first meeting and after each election of new board members the board shall elect a chairman from its members and select a secretary, treasurer and such officers or employees as it deems expedient or necessary for the accomplishment of its corporate objects. The secretary and treasurer need not be members of the board. At the meeting the board, by ordinance, shall define the first and subsequent fiscal years of the district, and shall adopt a corporate seal and bylaws, which shall determine the times for the annual election of officers and of other regular and special meetings of the board and shall contain the rules for the transaction of other business of the district and for amending the bylaws.

2. Each director of any district shall devote such time to the duties of the office as the faithful discharge thereof may require, including educational programs provided by the state, and may be reimbursed for [his] such director's actual expenditures in the performance of [his] the director's duties on behalf of the district.

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 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.

2. 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. A regulatory ordinance of a district adopted [under] pursuant to 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. [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.] 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] 190.001 to 190.250, the following words and terms mean:

(1) "Advanced life support" (ALS), an advanced 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 190.250;

[(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 dualpurpose 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 actually 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 to monitor the individual's condition 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 attendantdriver, 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) "Attendantdriver", a person who is qualified as an attendant and a driver;]

(3) "Ambulance service", any person or entity that provides emergency or nonemergency medical transportation and services in compliance with sections 190.001 to 190.250, and the rules promulgated by the department pursuant to sections 190.001 to 190.250;

(4) "Ambulance service area", a specific geographic area in which an ambulance service is authorized to operate pursuant to sections 190.001 to 190.250;

(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 190.250;

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

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

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

(8) "Director", the director of the department of health, state of Missouri;

(9) "Emergency", a condition of recent onset and severity that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent and unscheduled medical care is required;

(10) "Emergency medical dispatcher", a person who receives 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 190.250;

(11) "Emergency medical response agency", an entity that uses public highways or streets to regularly provide a level of care that includes first response, basic life support or advanced life support;

(12) "Emergency medical services for children (EMSC) 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;

(13) "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;

(14) "Emergency medical technician", persons trained in emergency medical care in accordance with standards prescribed by sections 190.001 to 190.250, or by rules and regulations pursuant to sections 190.001 to 190.250, who provide emergency medical services in accord with their respective levels of training, which may range from basic life support to advanced life support;

(15) "Emergency medical technician-basic" or "EMT-B", a person who has successfully completed a course of instruction in basic life support and is licensed by the department in accordance with standards prescribed by sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250;

(16) "Emergency medical technician-paramedic" or "EMT-P", a person who has successfully completed a course of instruction in advanced life support care and is licensed by the department in accordance with standards prescribed by sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250;

(17) "Emergency services", any health care services provided to evaluate and treat medical conditions of recent onset or severity that would lead a prudent layperson, possessing an average knowledge of health and medicine, to believe that urgent and unscheduled medical care is required;

(18) "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 190.250;

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

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

(21) "Local physician medical [advisor" or "local physician medical advisory committee] director", a physician or group of physicians licensed pursuant to chapter 334, RSMo, [appointed] designated 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] director shall have the responsibility to monitor [prehospital] medical care and [ensure that prehospital] establish standards of care and protocols [are met];

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

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

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

[(11) "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 190.001 to 190.250, 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, 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) "Political subdivision", any municipality, city, county, city not within a county, ambulance district or fire protection district located in whole or in part within this state which provides or has authority to provide an ambulance service;

(27) "Protocol", a predetermined, written medical care guideline, including standing orders;

(28) "Regional EMS committee", a committee formed within an emergency medical services region to advise the state council on EMS and the department;

(29) "Regional emergency medical services system", an organization of hospitals, ambulance 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;

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

(31) "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;

(32) "Trauma center", a hospital that has been designated as such by the department of health pursuant to rules adopted by the department of health pursuant to section 190.001 to 190.250.

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

2. The council shall have representation from each EMS region and representation from appropriate areas of adult and pediatric emergency medical services.

3. The members of the council and subcommittees shall serve without compensation except that the department 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 regulations on how to improve the statewide emergency medical service system. The council shall advise the governor, the general assembly and the department on all aspects of the emergency medical service system.

190.102. 1. The department shall designate through regulation EMS regions and committees. The purpose of the EMS regional committees is to better coordinate the emergency resources in the region, to improve public and professional education, to foster cooperation in research and to develop standards, protocols and policies.

2. The members of the committees shall serve without compensation except that the department shall budget for reasonable travel expenses and meeting expenses related to the functions of the committees, subject to appropriation by the general assembly.

190.103. 1. The director shall appoint one physician from each of the EMS regions with expertise in emergency medical services to serve as an EMS medical director to the department. The EMS medical directors shall advise the department on matters relating to medical control and medical direction in accordance with sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250.

2. Each ambulance service is required to have a local physician medical director. The medical director will provide medical direction to the ambulance service, including the development of triage, treatment and transport protocols in accordance with sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250.

3. The medical director in cooperation with the service 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.

190.104. 1. The department is authorized to establish a program in accordance with standards prescribed by sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250 to improve the quality of emergency care for pediatric patients throughout the state and to implement a comprehensive pediatric emergency medical services system.

2. The department is authorized to receive contributions, grants, donations or funds from any private 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 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 for an ambulance issued pursuant to the provisions of sections [190.100 to 190.195] 190.001 to 190.250.

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 attendantdriver 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 attendantdriver or attendant license.] emergency medical technician license; 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 emergency medical technician license. Each ambulance service is responsible for assuring that any person driving its ambulances is competent in emergency vehicle operations.

3. No person, as either owner, agent or otherwise, who holds a currently valid license for an ambulance service, shall, incident to [his] such person's business or service of transporting patients, transport, carry or convey patients in any vehicle other than an ambulance, but no such licenses shall be required for an ambulance service, or for the attendant[, attendantdriver, 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 at the request of the local ambulance service in the case of an emergency or major catastrophes; 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 service shall be used to pick up patients within Missouri [for transportation to locations within Missouri, except in emergency, unless the driver, attendant and attendantdriver 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] except as provided in subdivision (1) of this subsection.

4. The issuance of a license [under] pursuant to the provisions of sections [190.100 to 190.195] 190.001 to 190.250 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. Sections [190.100 to 190.195] 190.001 to 190.250 shall not preclude the adoption of any law, ordinance or regulation [not in conflict with] more stringent than this statute by any county, municipality or political subdivision.

6. 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. Sections [190.100 to 190.195] 190.001 to 190.250 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.

190.107. 1. The department shall have the authority and responsibility to license, suspend, revoke or refuse to renew licensure of an air ambulance service for just cause in accordance with standards prescribed by sections 190.001 to 190.250, excluding section 190.113, 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;

(8) Convenience and necessity hearings;

(9) Records and forms;

(10) Equipment requirements; and

(11) Five-year license renewal.

2. In the event that two or more ambulance service areas encompass all or a portion of the same area, the department may not prohibit an air ambulance service from providing service in any part of such area solely because more than one air ambulance service operates in such area.

190.108. The department shall have the authority and responsibility to license, suspend, revoke, or refuse to renew licensure of a ground ambulance service for just cause in accordance with standards prescribed by sections 190.001 to 190.250, and rules adopted by the department pursuant to sections 190.001 to 190.250, 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) Convenience and necessity hearings;

(7) Primary ambulance service areas;

(8) Records and forms;

(9) Medical control plans;

(10) Medical director qualifications; and

(11) Standards for medical communications.

190.113. 1. All ground ambulance services in existence before April, 1996, shall maintain their service areas in effect before April 2, 1996, if the area did not overlap with the emergency ground ambulance service areas of another ground ambulance service. Ground ambulance services that have overlapping emergency ground ambulance service areas shall develop plans by December 31, 1996, for the coordination of emergency and nonemergency services which the department shall approve. The plans shall include but not be limited to: mutual aid, tiered response; 9-1-1 and other dispatching procedures; and call referral procedures. The development of an approved plan shall be a condition of licensure. If the department finds that patient care has been compromised as a result of failure to comply with the provisions of the plan, the department may take licensure action against one or more of the ground ambulance services participating in the plan, all as set forth in regulations which the department is hereby authorized to promulgate. If no agreement is reached by December 31, 1996, then the department shall develop nonoverlapping service areas after first holding a public hearing. The department shall not change the jurisdictional boundaries of any ground ambulance service voted in by the people.

2. If a new ground ambulance service is voted in by the people after April 1, 1996, then the department shall grant licensure provided that the new ground ambulance service meets the standards as set forth within sections 190.015 to 190.185. Any new ground ambulance service shall have one hundred eighty days from its inception to submit plans for the coordination of emergency and nonemergency service with other ground ambulance services which have overlapping emergency ground ambulance service areas which the department shall approve. The plans shall include but not be limited to: mutual aid; tiered response; 9-1-1 and other dispatching procedures; and call referral procedures. The development of an approved plan shall be a condition of licensure. If the department finds that patient care has been compromised as a result of failure to comply with the provisions of the plan, the department may take licensure action against one or more of the ground ambulance services participating in the plan, all as set forth in regulations which the department is hereby authorized to promulgate. If no agreement is reached within one hundred eighty days, then the department shall develop nonoverlapping service areas after first holding a public hearing. The department shall not change the jurisdictional boundaries of any ground ambulance service voted in by the people. Nothing in this section shall require or allow the provision of emergency services below the minimum state standards prescribed pursuant to sections 190.015 to 190.185.

3. No provision of this section is intended to limit or supersede the powers, given for fire districts, pursuant to chapter 321, RSMo, or ambulance districts pursuant to chapter 190.

4. Any ground ambulance service provider shall not discriminate regarding transportation of the emergency patient on the basis of race, sex, age, color, religion, national origin, ancestry or handicap.

190.131. The department shall have the authority to certify training programs for first responders and emergency medical dispatchers in accordance with standards prescribed by sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250.

190.133. Any public or private individual or organization which provides advanced life support or early defibrillation to the public, exclusive of transportation, shall be licensed by the department in accordance with standards prescribed by sections 190.001 to 190.250, and rules adopted by the department pursuant to sections 190.001 to 190.250, including, but not limited to:

(1) A licensure period of five years;

(2) License fees;

(3) Protocols;

(4) Medical direction;

(5) Records and forms; and

(6) Memorandum of understanding with local ambulance services.

190.142. The department shall have the authority and responsibility to license, place on probation, suspend, revoke, or refuse to renew licensure for just cause and with due process all levels of emergency medical technicians in accordance with standards prescribed by sections 190.001 to 190.250 and rules adopted by the department pursuant to sections 190.001 to 190.250, including but not limited to:

(1) Prescribe education and training requirements based on the 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 190.250;

(2) Prescribe licensure testing requirements;

(3) License individuals who have met the department's education, training and testing requirements;

(4) Prescribe continuing education and relicensure requirements;

(5) Relicense individuals as an EMT-B or EMT-P, at least every four years based on their compliance with continuing education and relicensure requirements;

(6) Charge each candidate for licensure a fee; and

(7) Prescribe criteria for moral unfitness or patient care incompetency.

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, 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.] Any action taken by the department as authorized in chapter 190, may be appealed within thirty days by filing an appeal with the administrative hearing commission. Provisions of chapter 536, RSMo, and section 621.045, RSMo, shall apply.

[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 attendantdriver, 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.]

190.175. 1. The department shall develop and administer a uniform data collection system on all ambulance runs and injured patients, as defined by the department for the purpose of injury etiology, patient care outcome, peer review, 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. The department of health shall not require disclosure by hospitals of data elements pursuant to this section unless those data elements are recommended by a federal agency or were submitted to the department as of January 1, 1996, 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. Information obtained by the department pursuant to the provisions of this section shall not be public information. Reports and studies prepared by the department based upon such information which are not for peer review purposes shall be public information. The department may authorize the use of the data by other research organizations pursuant to the provisions of section 192.067, RSMo. The department shall not release data in a form which could be used to identify a patient or hospital without the permission of the patient or hospital.

190.180. 1. Any person violating, or failing to comply with, the provisions of [sections 190.100 to 190.195] this chapter 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] this chapter 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] this chapter, 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] this chapter.

190.181. No person, public agency or governmental body authorized to conduct activities pursuant to sections 190.001 to 190.250 or rules promulgated pursuant to sections 190.001 to 190.250 who in good faith exercises their responsibilities pursuant to sections 190.001 to 190.250 shall be liable for damages in any civil action based on such activities unless an act or omission during the course of such activities constitutes negligent or willful and wanton misconduct.

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, attendantdrivers 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 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 council. No rule or portion of a rule promulgated [under] pursuant to the authority of sections [190.093 to 190.249] 190.001 to 190.250 shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

190.190. Any ambulance[, attendant or attendantdriver which is] service or personnel 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] pursuant to 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.

190.196. 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 190.250, or by rules adopted pursuant to sections 190.001 to 190.250, unless and until the person so employed possesses all licenses, certificates or authorizations that are so 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 with the requirements of sections 190.001 to 190.250.

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. Insurance carriers and managed care plans shall pay benefits directly to the provider agency of emergency services.

2. Insurance carriers and managed care plans shall not prohibit or discourage the use of the 911 system when emergency services are needed as defined in sections 190.001 to 190.250 and shall not require prior authorization or retrospectively deny payment for a plan enrollee's use of emergency services as defined in section 190.100. This includes services provided to fulfill the obligation of section 1867 of the Social Security Act otherwise known as the Patient Transfer Act.

3. If a request for immediate emergency service is made to an EMS system which is not their 911 provider then the 911 provider will be notified immediately for joint response to ensure the most rapid response.

190.241. 1. The department of health shall designate a hospital as [a] an adult, pediatric or adult/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 of health shall, not less than once every [five] six years, conduct an onsite 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 of health 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 190.001 to 190.250 or rules adopted by the department pursuant to sections 190.001 to 190.250, their trauma center designation shall be revoked.

3. The department of health 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. No hospital shall hold itself out to the public as an adult, pediatric or adult/pediatric trauma center unless it is designated as such by the department of health.

5. 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.

190.243. 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 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.

354.400. As used in sections 354.400 to 354.550, the following terms [shall] mean:

(1) "Basic health care services", health care services which an enrolled population might reasonably require in order to be maintained in good health, including, as a minimum, emergency care, inpatient hospital and physician care, and outpatient medical services;

(2) "Director", the director of the department of insurance;

(3) "Emergency services", those health care services provided in a licensed hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent or unscheduled medical care is required;

(4) "Enrollee", an individual who has been enrolled in a health maintenance organization;

[(4)] (5) "Evidence of coverage", any certificate, agreement, or contract issued to an enrollee setting out the coverage to which [he] the enrollee is entitled;

[(5)] (6) "Health care services", any services included in the furnishing to any individual of medical or dental care or hospitalization, or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability;

[(6)] (7) "Health maintenance organization", any person which undertakes to provide or arrange for basic and supplemental health care services to enrollees on a prepaid basis, or which meets the requirements of section 1301 of the United States Public Health Service Act;

[(7)] (8) "Health maintenance organization plan", any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services and at least part of such arrangement consists of providing and assuring the availability of basic health care services to enrollees, as distinguished from mere indemnification against the cost of such services, on a prepaid basis through insurance or otherwise, and as distinguished from the mere provision of service benefits under health service corporation programs;

[(8)] (9) "Individual practice association", a partnership, corporation, association, or other legal entity which delivers or arranges for the delivery of health care services and which has entered into a services arrangement with persons who are licensed to practice medicine, osteopathy, dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health profession and a majority of whom are licensed to practice medicine or osteopathy. Such an arrangement shall provide:

(a) That such persons shall provide their professional services in accordance with a compensation arrangement established by the entity; and

(b) To the extent feasible for the sharing by such persons of medical and other records, equipment, and professional, technical, and administrative staff;

[(9)] (10) "Medical group/staff model", a partnership, association, or other group:

(a) Which is composed of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals (including dentists, chiropractors, pharmacists, optometrists, and podiatrists) as are necessary for the provisions of health services for which the group is responsible;

(b) A majority of the members of which are licensed to practice medicine or osteopathy; and

(c) The members of which (i) as their principal professional activity over fifty percent individually and as a group responsibility engaged in the coordinated practice of their profession for a health maintenance organization; (ii) pool their income from practice as members of the group and distribute it among themselves according to a prearranged salary or drawing account or other plan, or are salaried employees of the health maintenance organization; (iii) share medical and other records and substantial portions of major equipment and of professional, technical, and administrative staff; (iv) establish an arrangement whereby an enrollee's enrollment status is not known to the member of the group who provides health services to the enrollee;

[(10)] (11) "Person", any partnership, association, or corporation;

[(11)] (12) "Provider", any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services;

[(12)] (13) "Uncovered expenditures", the costs of health care services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization, or those costs which a provider has not agreed to forgive enrollees if the provider is not paid by the health maintenance organization.

354.535. [In the event that] 1. If a pharmacy, operated by or contracted with by a health maintenance organization, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to a [member] enrollee of a health maintenance organization. No health maintenance organization shall refuse to pay the pharmacists any payment due the enrollee under the terms of the policy or contract.

2. Health maintenance organization plan shall include twenty-four hours access to emergency services. A plan may not require prior authorization for emergency services, which include a medical screening exam and stabilizing treatment as defined in Section 1867 of the Social Security Act.

3. A health maintenance organization plan may require prior authorization for medically necessary services arising from such screening exam. A health maintenance organization plan or its contracting medical providers shall provide twenty-four hour access for enrollees and providers to request timely authorization for medically necessary care. Prior authorization shall be deemed to be approved unless the request for authorization is denied within thirty minutes. The access line shall be staffed twenty-four hours a day. The personnel staffing the line shall have access to a physician whenever necessary to make a determination regarding preauthorization.

4. A health maintenance organization plan shall reimburse providers for emergency services, federally mandated screening examinations as required by Section 1867 of the Social Security Act, and care of its enrollees, until such care results in the stabilization of the enrollee and the health maintenance organization plan assumes care of the enrollee, whether or not such providers have a contractual relationship with the health maintenance organization plan.

5. If the health maintenance organization staff person licensed by the state of Missouri to make determinations and give authorization for treatment and the attending physician disagree concerning the proper treatment for an enrollee who, following emergency services, is unstable as defined by section 1867 of the Social Security Act, the health maintenance organization shall take all legal and financial responsibility if the health maintenance organization acts against the recommendations of the attending physician.

6. If a primary care physician or health maintenance organization has authorized the evaluation or treatment of an enrollee, the health maintenance organization may not retrospectively deny the authorization for such evaluation and treatment.

Section 1. (1) After August 28, 1996, ambulance districts in the state of Missouri may contract out to a private company to provide ambulance service only if a majority of voters of the political subdivision authorize such a proposal at a public election.

(2) The ballot of submission shall be in the following form:

Shall the ..................... (insert the name of the ambulance district) contract out the ambulance service of the district to a private company.

* Yes * No

If a majority of the votes cast on the proposal by the qualified voters voting thereon are in favor of the proposal, then the ordinance shall be in effect as provided herein. If a majority of the votes cast by the qualified voters voting are opposed to the proposal, then the ambulance district shall have no power to privatize the ambulance service of the ambulance district.

[190.073. 1. An ambulance district which is comprised of the major portion of each of two or more counties may be divided on the border between the counties into separate ambulance districts, each of which shall have the powers and responsibilities of an ambulance district formed pursuant to sections 190.010 to 190.085, and the original ambulance district dissolved in the following manner:

(1) Upon the filing of a petition containing the signatures of no less than ten percent of the registered voters residing within the district with the county clerk of the county in which the greater part of the district is situated, or upon the motion of a majority of the members of the board of directors of the ambulance district, and the simultaneous filing by the petitioners or the board of directors, respectively, of a plan for the equitable disposition of the assets of the district, the county commission shall, upon approval of such plan by majority vote, submit the question to the voters in the district using the same procedure to the extent practicable as is provided for the submission of the question for forming an ambulance district. The plan shall be included in a legal notice published pursuant to section 115.127, RSMo. The plan for the disposition of assets may provide for the transfer or liquidation of assets or both. The plan may also provide that proceeds from any liquidation of assets be:

(a) Distributed equitably among the districts to be formed; or

(b) Refunded to taxpayers of the original district, except that refund payments shall be computed on the ratio of each taxpayer's tax payment to the total tax collection for the last taxable year for which the district collected taxes; or

(c) Applied to the payment of bonded indebtedness of the original district; or

(d) Distributed using any combination of paragraph (a), (b), or (c) of this subdivision;

(2) The question shall be submitted in substantially the following form:

Shall the ................ ambulance district be divided into ............... (number) separate ambulance districts, as described in the legal notice of election, for the establishment and operation of ambulance services within the boundaries of said proposed districts and having the powers to impose a property tax not to exceed the annual rate of fifteen cents on the one hundred dollars assessed valuation without voter approval and such additional tax as may be approved by vote thereon, to be known as the "............. Ambulance District" and the "................ Ambulance District", as prayed for by petition filed with the county clerk of ............. County, Missouri, on the .......... day of ......., 19....?

(3) If the question receives a majority of the votes cast in each of the ambulance districts to be formed by the division of the original district, the original ambulance district shall be dissolved for all purposes within one hundred fifty days or when each of the new districts becomes operational, whichever first occurs, except that if general obligation indebtedness exists the original district shall continue to exist solely for the purpose of levying and collecting taxes to pay such indebtedness. The plan for the disposition of assets shall be implemented upon passage;

(4) The results of the submission of the question shall be entered upon the records of the commission and a certified copy thereof shall be filed with the county clerk of the other county in which the affected district lies, who shall cause the same to be spread upon the records of the county commission. If the order shows that the question to organize the district received a majority of the votes cast in each of the ambulance districts to be formed, the order shall declare the district organized;

(5) Upon passage of a proposition to divide an existing ambulance district into separate ambulance districts, boards of trustees shall be elected for each new district pursuant to section 190.050.

2. Ambulance districts formed by the division of its predecessor district shall comply with the provisions of sections 190.010 to 190.085, relating to the formation of ambulance districts.]

[190.093. Notwithstanding the provisions of sections 190.100 to 190.190, when at any time a licensed ambulance owned and operated by an ambulance district is dispatched to answer an emergency call, and the services of a second licensed ambulance in such district are required at the same time, the district board at its discretion may allow such second ambulance to be staffed, only if a licensed attendant driver is not available, by an individual licensed as an attendant and by a driver approved by the district board who holds a current valid operator's or chauffeur's license from the state of Missouri.]

[190.095. Sections 190.100 to 190.195 shall not be construed so as to prohibit or limit in any way the transportation of persons who are sick, injured or otherwise incapacitated, by duly authorized police officers, sheriffs, or firemen in emergency situations in the exercise of their official duties in any city or county in this state.]

[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.]

[190.120. 1. No ambulance license shall be issued under sections 190.100 to 190.195, 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 selfinsurance coverage to provide for the payment of damages in an amount as prescribed by the board:

(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 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 selfinsured city not within a county, proof of selfinsurance, shall be submitted by all licensees required to provide such insurance under sections 190.100 to 190.195. The insurance policy, or proof of the existence of selfinsurance of a city not within a county, shall be submitted to the license officer, in such form as he may specify, for his approval prior to the issuance of each ambulance license.

3. Every insurance policy required by the provisions of this section shall contain or in the case of a selfinsured 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 selfinsured 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 selfinsurance 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 agent or employee, who may operate the same with the consent of the owner.

4. Every insurance policy or selfinsured 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 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 covered by such policy unless covered by another insurance policy in compliance with sections 190.100 to 190.195.]

[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, attendantdrivers, 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 attendantdrivers' 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 attendantdriver, 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, firstaid 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;

(c) Perform endotracheal intubation; and

(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

(c) Oxygen demand valves;

(3) Oxygen therapy;

(4) Oropharyngeal suctioning;

(5) Cardiopulmonary resuscitation procedures;

(6) Control accessible bleeding;

(7) Application of pneumatic antishock 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 attendantdriver's license.

2. The license officer shall issue a license to an attendant or attendantdriver, 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 attendantdriver'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 attendantdriver unless he holds a currently valid operator's or chauffeur's license from the state of Missouri; and

(6) For each applicant for a mobile emergency medical technician's license, that such applicant meets the requirements for attendant, subsection 2 above, 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 attendantdriver is not assignable or transferable.

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

[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 attendantdriver, 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.]

[190.160. The renewal of any license shall require conformance with all the requirements of sections 190.100 to 190.195 as upon original licensing.]

[190.165. 1. The license officer may suspend or revoke a license issued under the provisions of sections 190.100 to 190.195 for failure of a licensee to comply with the provisions of sections 190.100 to 190.195, or of regulations promulgated hereunder, or of any other applicable laws or ordinances or regulations, or he 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.

3. Upon suspension, revocation or termination of an ambulance license hereunder, no person shall be permitted to operate the ambulance. Upon suspension, revocation or termination of an attendant's or attendantdriver's license, the attendant or attendantdriver shall cease to drive or attend an ambulance, and no person shall employ or permit such individual to drive or attend an ambulance.

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

[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, EMTparamedics, 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.]

[190.245. 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, 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 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 and the names of hospitals, physicians and patients shall not be released by the department or members of review committees.]

[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 onehalf the cost of the ambulance or equipment.]