December 9, 2011
ASSIGNING AND REVOKING AMBULANCE SERVICE AREAS
By: James Orlando, Associate Analyst
You asked how the Department of Public Health (DPH) can revoke assigned service areas for emergency medical service (EMS) providers. This report updates OLR Report 99-R-0208.
The EMS statutes and DPH regulations establish circumstances in which DPH can revoke assigned EMS service areas. DPH may revoke an assigned service area from one provider and assign it to another if (1) the department, after investigation, determines that it is in the best interest of patient care in the affected town or towns to do so or (2) a local chief elected official petitions the department to do so and DPH determines that an emergency situation exists, the responder's performance is unsatisfactory, or it would be in the best interests of patient care. The department can also do so if the provider fails or refuses to agree to reasonable performance standards in a town's local EMS plan or fails to comply with data reporting requirements.
In addition, providers must hold a DPH license or certificate to be assigned a PSA. A provider whose license is suspended, revoked, or not renewed presumably would be disqualified from holding a PSA.
PRIMARY SERVICE AREAS
The state's emergency medical service delivery system coordinates emergency services to minimize the time between the occurrence of a sudden injury or illness and the delivery of care at the scene. It establishes tiers of care in order of increasing life-saving skills (i.e., first responder, basic ambulance, and advanced life support) and assigns geographic areas, called primary service areas (PSAs), to specific EMS providers for each tier of service available in that area. PSAs may cover all or portions of several towns (CGS § 19a-175; Conn. Agencies Reg., § 19a-179-1).
Every EMS service must be available to respond to emergency calls in its PSA 24 hours a day, seven days a week, or must arrange with other certified or licensed response services to cover its PSA during non-operational hours with no reduction in level of service (Conn. Agencies Reg., § 19a-179-11). Every Connecticut town is part of a PSA for first responder and basic ambulance service and most have either a paramedic or paramedic intercept service.
By law, DPH must assign a responder for each PSA in the state (CGS § 19a-177). DPH assigns PSAs at each service level. Regulations specify the following factors that DPH must consider before assigning a PSA to a provider:
1. size of population to be served,
2. effect of proposed PSA responder assignment on other emergency medical service providers in the area,
3. geographic locations of the proposed PSA responder,
4. the proposed PSA responder's record of response time,
5. the proposed PSA responder's record of activation time,
6. the proposed PSA responder's level of licensure or certification, and
7. other factors which DPH determines are relevant to providing efficient and effective emergency medical services to the population.
DPH must also seek the advice and recommendations of the appropriate regional council and the chief administrative official of the affected town (Conn. Agencies Reg., § 19a-179-4(b)).
The law does not require PSAs to be renewed; the assignments are indefinite unless revoked. State law and regulations allow DPH to revoke or take away a PSA assignment in the following circumstances.
Town Petition. A municipality can petition the DPH commissioner for a responder's removal (1) at any time based on an allegation that an emergency exists and the safety, health, and welfare of the primary service area's citizens are jeopardized by the responder's performance or (2) not more than once every three years on the basis of unsatisfactory responder performance under the local EMS plan established by the town and associated agreements or contracts. The law provides that this applies to any PSA responder (1) notified for initial response, (2) responsible for basic life support, or (3) responsible for intensive and complex prehospital care above basic life support that is consistent with acceptable emergency medical practices under the control of physician and hospital protocols. A hearing on a petition is a contested case under the Uniform Administrative Procedure Act (UAPA).
After a hearing following a town's petition for removal, the DPH commissioner can (1) revoke the responder's primary service area assignment and require the affected town's chief administrative official to submit a plan acceptable to the commissioner for alternative primary service responder responsibilities, (2) issue an order for alternative provision of EMS services, or (3) do both. To take any of these actions, she must find that (1) an emergency exists and the responder's performance jeopardizes the health and safety of those in the affected area, (2) the responder's performance is unsatisfactory based on the local EMS plan, or (3) it is in the best interests of patient care (CGS § 19a-181c).
A municipality can also ask the commissioner to hold a hearing if it cannot reach a written agreement with its responder on performance standards. The hearing, which is not a contested case under the UAPA, must be held within 90 days after DPH receives the petition. In the hearing, the commissioner must determine if the performance standards in the town's local EMS plan are reasonable, based on the statewide plan for the coordinated delivery of EMS, model local EMS plans, and the standards and agreements used by similar municipalities.
If the commissioner determines, after the hearing, that the performance standards in the local EMS plan are reasonable, the PSA responder has 30 days to agree to them. If the responder fails or refuses to do so, the commissioner can (1) revoke the responder's PSA assignment and require the town's chief administrative official to submit an acceptable plan for alternative primary area responder responsibilities, (2) issue an order for alternative EMS provision, or (3) do both.
If the commissioner determines, after the hearing, that the adopted standards are unreasonable, she must provide reasonable performance standards based on the statewide plan for coordinated EMS delivery, model EMS plans, and the standards and agreements used by similar towns. If the town refuses to agree to such performance standards, the responder must meet the minimum performance standards in state regulations (CGS § 19a-181d).
DPH or Regional Council Request Based on Patient Care. DPH can revoke a PSA assignment if the commissioner determines that doing so is in the best interests of patient care (CGS § 19a-177(12)). In addition to a request from the town as specified above, DPH regulations authorize the department to revoke an assignment due to patient care on its own initiative or upon the recommendation of the appropriate regional council. Both the responder and regional council can present evidence and arguments to the commissioner (Conn. Agencies Reg., § 19a-179-4(d)).
Failure to Provide Service Data. By law, DPH must collect specific EMS data from licensed and certified ambulance services and other EMS-related entities on a quarterly basis and prepare an annual report based on this data. The data that the services must provide includes the number of EMS calls received; level of EMS required; response times; number of passed, cancelled, and mutual aid calls; and prehospital data for the nonscheduled transport of patients.
The commissioner can impose certain penalties on those that fail to submit the required information. DPH must issue a written order directing the service to comply with the reporting requirement if (1) the service does not submit information for six consecutive months or (2) DPH believes the service knowingly or intentionally submitted incomplete or false information.
If the service does not fully comply with the order within three months of its issuance, DPH (1) must hold a hearing (under the UAPA) at which the service must show cause why its PSA assignment should not be revoked and (2) can take a variety of disciplinary actions against the service (e.g., license revocation or suspension, censure, letter of reprimand, probation, civil penalties) as it deems appropriate (CGS § 19a-177(8)).
License Rejection, Suspension, or Revocation. Another possible way to remove a provider from a PSA is to reject its license renewal application or otherwise suspend or revoke its license. By law, commercial providers must be licensed and must renew their licenses annually (volunteer or municipal ambulance services must have valid certificates instead of licenses) (CGS § 19a-180). The statutes and the regulations do not specifically provide for the effect of denying a license renewal on the PSA assignment, except that PSA providers must have a DPH license or certification. It appears that a provider who no longer has a valid and active license would be disqualified from holding a PSA. The license rejection, revocation, or suspension process can be lengthy. By law, providers must have an opportunity to show compliance and may appeal a decision (CGS § 19a-180 and Conn. Agencies Reg., § 19a-179-15). License rejection, revocation, or suspension would also prevent a provider from serving its other PSAs.