(a) Purpose: Acquiring, issuing, and maintaining an EMS Providers License.
(b) EMS in Texas is a delegated practice, as written in Occupations Code, §157.003.
(c) Application requirements for an Emergency Medical Services (EMS) Provider License.
  (1) An applicant for an initial EMS provider license shall submit a completed application to the department on the required official forms, following the department's written process.
  (2) The nonrefundable application fee of $500 per provider plus $180 for each EMS vehicle to be operated under the license shall accompany the application.
  (3) The department will process the EMS provider license application as per §157.3 of this title (relating to Processing EMS Provider Licenses and Applications for EMS Personnel Certification and Licensure).
  (4) An EMS provider holding a valid license or authorization from another state; whose service area adjoins the State of Texas; who has in place a written mutual aid agreement, with a licensed Texas EMS provider, and who when requested to do so by a licensed Texas EMS provider, responds into Texas for emergency mutual aid assistance, may be exempt from holding a Texas EMS provider license, but will be obligated to perform to the same medical standards of care required of EMS providers licensed by their home state.
  (5) A fixed-wing or rotor-wing air ambulance provider, appropriately licensed by the state governments of New Mexico, Oklahoma, Arkansas, Kansas, Colorado or Louisiana may apply for a reciprocal issuance of a provider license, and the application would not require staffing by Texas EMS certified or licensed personnel. A nonrefundable administrative fee of $500 per provider in addition to a nonrefundable fee of $180 for each EMS aircraft to be operated in Texas under the reciprocal license shall accompany the application.
  (6) An applicant for an EMS provider license that provides emergency prehospital care is exempt from payment of department licensing and authorization fees if the firm is staffed with at least 75% volunteer personnel, has no more than five full-time staff or equivalent, and the firm is recognized as a §501(c)(3) nonprofit corporation by the Internal Revenue Service. An EMS provider who compensates a physician to provide medical supervision may be exempt from the payment of department licensing and authorization fees if all other requirements for fee exemption are met.
  (7) Required documents that shall accompany a license application.
    (A) Document verifying volunteer status, if applicable.
    (B) Map and description of service area, a list of counties and cities in which applicant proposes to provide primary emergency service and a list of all station locations with address and telephone and facsimile transmission numbers for each station.
    (C) Declaration of organization type and profit status.
    (D) Declaration of Provider Name.
      (i) The legal name of the EMS provider cannot include the name of the city, county or regional advisory council within or in part, unless written approval is given by the individual city, county or regional advisory council respectively.
      (ii) The EMS provider operational name cannot include the name of the city, county or regional advisory council within or in part, unless written approval is given by the individual city, county or regional advisory council respectively. A proposed provider name is deemed to be deceptively similar to an established licensed EMS provider if it meets the conditions listed in the Office of the Secretary of State rule, 1 Texas Administrative Code, §79.39 (relating to Deceptively Similar Name).
    (E) Declaration of Ownership.
    (F) Declaration of the address for the main location of the business, normal business hours and provide proof of ownership or lease of such location.
      (i) The normal business hours must be posted for public viewing.
      (ii) A service area map must be provided.
      (iii) Only one EMS provider license will be issued to each fixed address.
      (iv) The applicant shall attest that no other license EMS provider is at the provided business location or address.
      (v) The emergency medical services provider must remain in the same physical location for the period of licensure, unless the department approves a change in location.
    (G) Declaration of the administrator of record and any subsequently filed declaration of a new administrator shall declare the following, if the EMS provider is required to have an administrator of record as per Health and Safety Code, §773.0571 or §773.05712.
      (i) The administrator of record is not employed or otherwise compensated by another private for-profit EMS provider.
      (ii) The administrator of record meets the qualifications required for an emergency medical technician certification or other health care professional license with a direct relationship to EMS and currently holds such certification or license issued by the State of Texas.
      (iii) The administrator of record has submitted to a criminal history record check at the applicant's expense as directed in §157.37 of this title (relating to Certification or Licensure of Persons With Criminal Backgrounds).
      (iv) The administrator of record has completed an initial education course approved by the department regarding state and federal laws and rules that affect EMS in the following areas:
        (I) Health and Safety Code, Chapter 773 and 25 Texas Administrative Code, Chapter 157;
        (II) EMS dispatch processes;
        (III) EMS billing processes;
        (IV) Medical control accountability; and
        (V) Quality improvement processes for EMS operations.
      (v) The applicant will assure that its administrator of record shall annually complete eight hours of continuing education related to the Texas and federal laws and rules related to EMS.
      (vi) An EMS provider that is directly operated by a governmental entity, is exempt from this subparagraph, except for declaration of administrator of record.
      (vii) An EMS provider that held a license on September 1, 2013, and has an administrator of record who has at least eight years of experience providing EMS, the administrator of record is exempt from clauses (ii) and (iv) of this subparagraph.
    (H) Copies of Doing Business Under Assumed Name Certificates (DBA).
    (I) Completed EMS Personnel Form.
    (J) Staffing Plan that describes how the EMS provider provides continuous coverage for the service area defined in documents submitted with the EMS provider application. The EMS provider shall have a staffing plan that addresses coverage of the service area or shall have a formal system to manage communication when not providing services after normal business hours.
    (K) Completed EMS Vehicle Form.
    (L) Declaration of an employed medical director and a copy of the signed contract or agreement with a physician who is currently licensed in the State of Texas, in good standing with the Texas Medical Board, in compliance with Texas Medical Board rules, 22 Texas Administrative Code, Chapter 197, and in compliance with Title 3 of the Texas Occupations Code.
    (M) Completed Medical Director Information Form.
    (N) Treatment and Transport Protocols and policies addressing the care to be provided to adult, pediatric, and neonatal patients, and as stated in Health and Safety Code §773.112(d), must be approved and signed by the medical director.
    (O) A list of equipment as required on the EMS Provider initial and renewal application, with identifiable or legible serial numbers, supplies and medications; approved and signed by the medical director.
    (P) The applicant shall attest that all required equipment is permitted to be used by the EMS provider and provide proof of ownership or hold a long-term lease for all equipment necessary for the safe operation.
    (Q) The applicant shall attest that each authorized vehicle will have its own set of equipment required for each authorized vehicle to operate at the level of the service for which the provider is authorized.
    (R) Description of how the EMS provider will conduct quality assurance in coordination with the EMS provider medical director.
    (S) The applicant shall provide an attestation or provide documentation that it and/or its management staff will or continues to participate in the local regional advisory council.
    (T) Plan for how the provider will respond to disaster incidents including mass casualty situations in coordination with local and regional plans.
    (U) Copies of written Mutual Aid and/or Inter-local Agreements with EMS providers.
Cont'd...
(V) Documentation as required for subscription or membership program, if applicable.
    (W) Certificate of Insurance, provided by the insurer, identifying the department as the certificate holder and indicating at least minimum motor vehicle liability coverage for each vehicle to be operated and professional liability coverage. If applicant is a government subdivision, submit evidence of financial responsibility by self-insuring to the limit imposed by the tort claims provisions of the Texas Civil Practice and Remedies Code.
      (i) The applicant shall maintain motor vehicle liability insurance as required under the Texas Transportation Code.
      (ii) The applicant shall maintain professional liability insurance coverage in the minimum amount of $500,000 per occurrence, or as necessary per state law, with a company licensed or deemed eligible by the Texas Department of Insurance to do business in Texas or acceptable proof of self-insurance or captive insurance in order to secure payment for any loss or damage resulting from any occurrence arising out of, or caused by the care, or lack of care, of a patient.
    (X) The applicant shall provide copies of vehicle titles, vehicle lease agreements, copies of exempt registrations if applicant is a government subdivision, or an affidavit identifying applicant as the owner, lessee, or authorized operator for each vehicle to be operated under the license.
    (Y) The applicant shall provide documentation of the following, showing that the applicant, including its management staff possesses sufficient professional experience and qualifications related to EMS:
      (i) an attestation that its management staff have read the Texas Emergency Healthcare Act and the department's EMS rules in this chapter;
      (ii) proof of one year experience or education provided by a nationally recognized organization on emergency medical dispatch processes;
      (iii) proof of one year experience or education provided by a nationally recognized organization concerning EMS billing processes;
      (iv) proof of one year experience or education provided by a nationally recognized organization on medical control accountability; and
      (v) proof of one year experience or education provided by a nationally recognized organization on quality improvement processes for EMS operations.
    (Z) A copy of a letter of credit for the obtaining or renewing of an EMS Providers license, issued by a federally insured bank or savings institution:
      (i) in the amount of $100,000 for the initial license and for renewal of the license on the second anniversary of the date the initial license is issued;
      (ii) in the amount of $75,000 for renewal of the license on the fourth anniversary of the date the initial license is issued;
      (iii) in the amount of $50,000 for renewal of the license on the sixth anniversary of the date the initial license is issued;
      (iv) in the amount of $25,000 for renewal of the license on the eighth anniversary of the date the initial license is issued;
      (v) that shall include the names of all of the parties involved in the transaction;
      (vi) that shall include the names of the persons or entity, who owns the EMS provider operation and to whom the bank is issuing the letter of credit;
      (vii) that shall include the name of the person or entity, receiving the letter of credit; and
      (viii) an EMS provider that is directly operated by a governmental entity is exempt from this subsection.
    (AA) A copy of the surety bond in the amount of $50,000 issued to and provided to the Health and Human Services Commission by the applicant, participating in the medical assistance program operated under Human Resources Code, Chapter 32, the Medicaid managed care program operated under Government Code, Chapter 533, or the child health plan program operated under Health and Safety Code, Chapter 62. An EMS provider that is directly operated by a governmental entity is exempt from this subparagraph.
    (BB) Documentation evidencing applicant or management team has not been excluded from participation in the state Medicaid program.
    (CC) A copy of a governmental entity letter of approval that shall:
      (i) be from the governing body of the municipality in which the applicant is located and is applying to provide EMS;
      (ii) be from the commissioner's court of the county in which the applicant is located and is applying to provide EMS, if the applicant is not located in a municipality;
      (iii) include the attestation that the addition of another licensed EMS provider will not interfere with or adversely affect the provision of EMS by the licensed EMS providers operating in the municipality or county;
      (iv) include the attestation that the addition of another licensed EMS provider will remedy an existing provider shortage that cannot be resolved through the use of the licensed EMS providers operating in the municipality or county; and
      (v) include the attestation that the addition of another licensed EMS provider will not cause an oversupply of licensed EMS providers in the municipality or county.
  (8) Paragraph (7)(CC) of this subsection does not apply to renewal of an EMS provider license or a municipality, county, emergency services district, hospital, or EMS volunteer provider organization in this state that applies for an EMS provider license.
  (9) An EMS provider is prohibited from expanding operations to or stationing any EMS vehicles in a municipality or county other than the municipality or county from which the provider obtained the letter of approval under this subsection until after the second anniversary of the date the provider's initial license was issued, unless the expansion or stationing occurs in connection with:
    (A) a contract awarded by another municipality or county for the provision of EMS;
    (B) an emergency response made in connection with an existing mutual aid agreement; or
    (C) an activation of a statewide emergency or disaster response by the department.
  (10) Paragraph (9) of this subsection does not apply to renewal of an EMS provider license or a municipality, county, emergency services district, hospital, or EMS volunteer provider organization in this state that applies for an EMS provider license.
  (11) Paragraph (9) of this subsection does not apply to fixed or rotor wing EMS providers.
(d) EMS Provider License.
  (1) License.
    (A) Applicants who have submitted all required documents and who have met all the criteria for licensure will be issued a provider license to be effective for a period of two years from the date of issuance.
    (B) Licenses shall be issued in the name of the applicant.
    (C) License expiration dates may be adjusted by the department to create licensing periods less than two years for administrative purposes.
    (D) An application for an initial license or for the renewal of a license may be denied to a person or legal entity who owns or who has owned any portion of an EMS provider service or who operates/manages or who/which has operated/managed any portion of an EMS provider service which has been sanctioned by or which has a proposed disciplinary action/sanction pending against it by the department or any other local, state or federal agency.
    (E) The license will be issued in the form of a certificate which shall be prominently displayed in a public area of the provider's primary place of business.
    (F) An EMS Provider License issued by the department shall not be transferable to another person or entity.
  (2) Vehicle Authorization.
    (A) The department will issue an authorization for each vehicle to be operated by the applicant which meets all criteria for approval as defined in subsection (d) of this section.
    (B) A vehicle authorization shall be issued for the following levels of service, and a provider may operate at a higher level of service based on appropriate staffing, equipment and medical direction for that level. A vehicle authorization will include a level of care designation at one of the following levels:
      (i) Basic Life Support (BLS);
      (ii) BLS with Advanced Life Support (ALS) capability;
      (iii) BLS with Mobile Intensive Care Unit (MICU) capability;
      (iv) Advanced Life Support (ALS);
      (v) ALS with MICU capability;
      (vi) Mobile Intensive Care Unit (MICU);
      (vii) Air Medical:
        (I) Rotor wing; or
Cont'd...
(II) Fixed wing; and
      (viii) Specialized.
    (C) Change of Vehicle Authorization. To change an authorization to a different level the provider shall submit a request with appropriate documentation to the department verifying the provider's ability to perform at the requested level. A fee of $30 shall be required for each new authorization requested. The provider shall allow sufficient time for the department to verify the documentation and conduct necessary inspections before implementing service at the requested authorization level.
    (D) Vehicle Authorizations are not required to be specific to particular vehicles and may be interchangeably placed in other vehicles as necessary. The original Vehicle Authorization for the appropriate level of service shall be prominently displayed in the patient compartment of each vehicle:
    (E) Vehicle Authorizations are not transferable between providers.
    (F) A replacement of a lost or damaged license or authorization may be issued if requested with a nonrefundable fee of $10.
  (3) Declaration of Business Operational Name and Administration.
    (A) The applicant shall submit a list of all business operational names under which the service is operated. If the applicant intends to operate the service under a name or names different from the name for which the license is issued, the applicant shall submit certified copies of assumed name certificates.
    (B) A change in the operational name which the service is operated will require a new application and a prorated fee as determined by the department. A new provider number will be issued.
    (C) Name of Administrator of Record must be declared. The applicant shall submit a notarized document declaring the full name of the chief administrator, his/her mailing address and telephone number to whom the department shall address all official communications in regard to the license.
(e) Vehicles.
  (1) All EMS vehicles must be adequately constructed, equipped, maintained and operated to render patient care, comfort and transportation of adult, pediatric, and neonatal patients safely and efficiently. A pediatric and neonatal equipment list should be based on endorsed pediatric equipment national standards within the approved equipment list required by the medical director.
  (2) EMS vehicles must allow the proper and safe storage and use of all required equipment, supplies and medications and must allow all required procedures to be carried out in a safe and effective manner.
  (3) As approved by the department, EMS vehicles must meet a practical efficient minimum national ambulance vehicle body type, dimension and safety criteria standards.
  (4) All vehicles shall have an environmental system capable of heating or cooling the patient(s) and staff, in accordance with the manufacturer specifications, within the patient compartment at all times when in service and which allows for protection of medication, according to manufacturer specifications, from extreme temperatures if it becomes environmentally necessary. The provider shall provide evidence of an operational policy which shall list the parenteral pharmaceuticals authorized by the medical director and which shall define the storage and/or FDA recommendations. Compliance with the policy shall be incorporated into the provider's Quality Assurance process and shall be documented on unit readiness reports.
  (5) EMS vehicles shall have operational two-way communication capable of contacting appropriate medical resources and as outlined in the current Texas interoperability plan unless the vehicle is designated as being out of service using the form provided by the department.
  (6) EMS vehicles shall be in compliance with all applicable federal, state and local requirements unless the vehicle is designated out of service with the form provided by the department.
  (7) All EMS vehicles shall have the name of the provider and a current department issued EMS provider license number prominently displayed on both sides of the vehicle in at least 2 inch lettering and in contrasting color. The license number shall have the letters TX prior to the license number. This requirement does not apply to fixed or rotor wing aircraft.
(f) Substitution, replacement and additional EMS vehicles.
  (1) The EMS provider shall notify the department within five business days if the EMS provider substitutes or replaces a vehicle. No fee is required for a vehicle substitution or replacement.
  (2) The EMS provider shall notify the department if the EMS provider adds a vehicle to the provider's operational fleet prior to making the vehicle response-ready. A vehicle authorization request shall be submitted with a nonrefundable vehicle fee prior to the vehicle being placed into service.
(g) Staffing Plan Required.
  (1) The applicant shall submit a completed EMS Personnel Form listing each response person assigned to staff EMS vehicles by name, certification level, and department issued certification/license identification number.
  (2) An EMS provider responsible for an emergency response area that is unable to provide continuous coverage within the declared service areas shall publish public notices in local media of its inability to provide continuous response capability and shall include the days and hours of its operation. The EMS provider shall notify all the public safety-answering points and all dispatch centers of the days and hours when unable to provide coverage. The EMS provider shall submit evidence that reasonable attempts to secure coverage from other EMS providers have been made.
  (3) The applicant must provide proof at initial and renewal of license that all licensed or certified personnel have completed a jurisprudence examination approved by the department on state and federal laws and rules that affect EMS.
(h) Minimum Staffing Required.
  (1) BLS--When response-ready or in-service, authorized EMS vehicles operating at the BLS level shall be staffed at a minimum with two emergency care attendants (ECAs).
  (2) BLS with ALS capability--When response-ready or in-service below ALS two ECAs. Full ALS status becomes active when staffed by at least an emergency medical technician (EMT)-Intermediate or AEMT and at least an EMT.
  (3) BLS with MICU capability--When response-ready or in-service below MICU two ECAs. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.
  (4) ALS--When response-ready or in-service, authorized EMS vehicles operating at the ALS level shall be staffed at a minimum with one EMT Basic and one AEMT or EMT- Intermediate.
  (5) ALS with MICU capability--When response-ready or in-service below MICU shall require one EMT-Intermediate or AEMT and one EMT. Full MICU status becomes active when staffed by at least a certified or licensed paramedic and at least an EMT.
  (6) MICU--When response-ready or in-service, authorized EMS vehicles operating at the MICU level shall be staffed at a minimum with one EMT Basic and one certified or licensed EMT-Paramedic.
  (7) Specialized--When response-ready or in-service, EMS vehicles authorized to operate for a specialized purpose shall be staffed with a minimum of two personnel appropriately licensed and/or certified as determined by the type and application of the specialized purpose and as approved by the medical director and the department.
  (8) For air ambulance staffing requirements refer to §157.12(f) of this title (relating to Rotor-wing Air Ambulance Operations) or §157.13(g) of this title (relating to Fixed- wing Air Ambulance Operations).
  (9) When response-ready or in-service, authorized EMS vehicles may operate at a lower level than licensed by the department. When operating at the BLS level with an ALS/MICU ambulance, the EMS provider must have an approved security plan for the ALS/MICU medication as approved by the EMS provider medical director's protocol and/or policy.
  (10) As justified by patient needs, providers may utilize appropriately certified and/or licensed medical personnel in addition to those which are required by their designation levels. In addition to the care rendered by the required staff, the provider shall be accountable for care rendered by any additional personnel.
(i) Treatment and Transport Protocols Required.
  (1) The applicant shall submit written delegated standing orders for patient treatment and transport protocols and policies related to patient care which have been approved and signed by the provider's medical director.
  (2) The protocols shall have an effective date.
  (3) The protocols shall address the use of non-EMS certified or licensed medical personnel who, in addition to the EMS staff, may provide patient care on behalf of the provider and/or in the provider's EMS vehicles.
Cont'd...
(4) The protocols shall address the use of all required, additional, and/or specialized medical equipment, supplies, and pharmaceuticals carried on each EMS vehicle in the provider's fleet.
  (5) The protocols shall identify delegated procedures for each EMS Certification or license level utilized by the provider.
  (6) The protocols shall indicate specific applications, including geographical area and duty status of personnel.
(j) EMS Equipment, supplies, medical devices, parenteral solutions and pharmaceuticals.
  (1) The EMS provider shall submit a list, approved and signed by the medical director and fully supportive of and consistent with the protocols, of all medical equipment, supplies, medical devices, parenteral solutions and pharmaceuticals to be carried. The list shall specify the quantities of each item to be carried and shall specify the sizes and types of each item necessary to provide appropriate care for all age ranges appropriate to the needs of their patients. The quantities listed shall be appropriate to the provider's call volume, transport times and restocking capabilities.
  (2) All patient care equipment, and medical devices must be operational, appropriately secured in the vehicle at the time of providing patient care and response ready, and supplies shall be clean and fully operational. All patient care powered equipment shall have manual mechanical, spare batteries or an alternative power source, if applicable.
  (3) All solutions and pharmaceuticals shall be up to date and shall be stored and maintained in accordance with the manufacturer's and/or U.S. Federal Drug Administration (FDA) recommendations.
  (4) The requirements for air ambulance equipment and supplies are listed in 157.12(h) of this title or §157.13(h) of this title.
(k) The following equipment shall be present on each EMS in-service vehicle and on, or immediately available for, each response-ready vehicle as specified in the equipment list as required by the medical director's approved equipment list to include all state required equipment. The equipment list shall include equipment required for treatment and transport of adult, pediatric, and neonatal patients.
  (1) Basic Life Support (BLS):
    (A) Equipment required to administer the BLS scope of practice and incorporates the knowledge, competencies and basic skills of an EMT/ECA and additional skills as authorized by the EMS provider medical director. All BLS ambulances shall be able to perform treatment and transport patients receiving the following skills:
      (i) airway/ventilation/oxygenation;
      (ii) cardiovascular circulation;
      (iii) immobilization;
      (iv) medication administration - routes; and
      (v) single and multi-system trauma patients.
    (B) oropharyngeal airways;
    (C) portable and vehicle mounted suction;
    (D) bag valve mask units, oxygen capable;
    (E) portable and vehicle mounted oxygen;
    (F) oxygen delivery devices;
    (G) dressing and bandaging materials;
    (H) commercial tourniquet;
    (I) rigid cervical immobilization devices;
    (J) spinal immobilization devices;
    (K) extremity splints;
    (L) equipment to meet special patient needs;
    (M) equipment for determining and monitoring patient vital signs, condition or response to treatment;
    (N) pharmaceuticals, as required by the medical director's protocols;
    (O) an external cardiac defibrillator appropriate to the staffing level with two sets of adult and two sets of pediatric pads;
    (P) a patient-transport device capable of being secured to the vehicle, and the patient must be fully restrained per manufacturer recommendations; and
    (Q) an epinephrine auto injector or similar device capable of treating anaphylaxis.
  (2) Advanced Life Support (ALS):
    (A) equipment required to administer the ALS scope of practice and incorporates the knowledge, competencies and basic and advanced skills of an AEMT and additional skills as authorized by the EMS provider medical director. All ALS ambulances shall be able to perform treatment and transport patients receiving the following skills, including all required BLS equipment to perform treatment and transport patients receiving the following skills:
      (i) airway/ventilation/oxygenation;
      (ii) cardiovascular circulation;
      (iii) immobilization;
      (iv) medication administration - routes; and
      (v) intravenous (IV) initiation/maintenance fluids.
    (B) all required BLS equipment;
    (C) advanced airway equipment;
    (D) IV equipment and supplies;
    (E) pharmaceuticals as required by medical director protocols; and
    (F) wave form capnography or state approved carbon dioxide detection equipment must be used after January 1, 2018, when performing or monitoring endotracheal intubation.
  (3) MICU:
    (A) equipment required to administer the knowledge, competencies and advanced skills of a paramedic, and additional skills as authorized by the EMS provider medical director. All MICU ambulances shall be able to perform treatment and transport patients receiving the following skills:
      (i) airway/ventilation/oxygenation;
      (ii) cardiovascular circulation;
      (iii) immobilization;
      (iv) medication administration - routes; and
      (v) intravenous (IV) initiation/maintenance fluids.
    (B) all required BLS and ALS equipment;
    (C) with transmitting 12-lead capability cardiac monitor/defibrillator by January 1, 2020; and
    (D) pharmaceuticals as required by medical director protocols.
  (4) BLS with ALS Capability:
    (A) all required BLS equipment, even when in service or response ready at the ALS level; and
    (B) all required ALS equipment, when in service or response ready at the ALS level.
  (5) BLS with MICU Capability:
    (A) all required BLS equipment, even when in service or response ready at the MICU level; and
    (B) all required MICU equipment, when in service or response ready at the MICU level.
  (6) ALS with MICU Capability:
    (A) all required ALS equipment, even when in service or response ready at the MICU level; and
    (B) all MICU equipment, when in service or response ready at the MICU level.
  (7) In addition to medical supplies and equipment as defined in subsection (k) of this section, EMS vehicles must also have:
    (A) a complete and current copy of written or electronic formatted protocols approved and signed by the medical director; with a current and complete equipment, supply, and medication list available to the crew;
    (B) operable emergency warning devices;
    (C) personal protective equipment for the EMS vehicle staff, including at least:
      (i) protective, non-porous gloves;
      (ii) medical eye protection;
      (iii) medical respiratory protection must be available per crew member, meeting National Institute for Occupational Safety and Health (NIOSH) approved N95 or greater standards;
      (iv) medical protective gowns or equivalent; and
      (v) personal cleansing supplies;
    (D) sharps container;
    (E) biohazard bags;
    (F) portable, battery-powered flashlight (not a pen-light);
    (G) a mounted, currently inspected, 5 pound ABC fire extinguisher (not applicable to air ambulances);
    (H) "No Smoking" signs posted in the patient compartment and cab of vehicle;
    (I) a current emergency response guide book, or an electronic version that is available to the crew (for hazardous materials); and
    (J) each vehicle will carry 25 triage tags in coordination with the Regional Advisory Council (RAC).
  (8) As justified by specific patient needs, and when qualified personnel are available, EMS providers may appropriately utilize equipment in addition to that which is required by their authorization levels. Such equipment must be consistent with protocols and/or patient- specific orders and must correspond to personnel qualifications.
Cont'd...
(l) National accreditation. If a provider has been accredited through a national accrediting organization approved by the department and adheres to Texas staffing level requirements, the department may exempt the provider from portions of the license process. In addition to other licensing requirements, accredited providers shall submit:
  (1) an accreditation self-study;
  (2) a copy of the formal accreditation certificate; and
  (3) any correspondence or updates to or from the accrediting organization which impact the provider's status.
(m) Subscription or Membership Services. An EMS provider that operates or intends to operate a subscription or membership program for the provision of EMS within the provider's service area shall meet all the requirements for an EMS provider license as established by the Health and Safety Code, Chapter 773, and the rules adopted thereunder, and shall obtain department approval prior to soliciting, advertising or collecting subscription or membership fees. To obtain department approval for a subscription or membership program, the EMS provider shall:
  (1) Obtain written authorization from the highest elected official (County Judge or Mayor) of the political subdivision(s) where subscriptions will be sold. Written authorization must be obtained from each County Judge if subscriptions are to be sold in multiple counties.
    (A) The County Judge must provide written authorizations, if subscriptions are to be sold throughout a county.
    (B) The Mayor may provide written authorization if subscriptions are sold exclusively within the boundaries of an incorporated town or city.
    (C) If an EMS provider is not the primary emergency provider in any area where they are going to sell a subscription plan, written notification must be provided to the participants receiving subscription plan stating that the EMS Provider is not the primary emergency provider in this area. A copy of this documentation should be provided to the primary emergency provider and the department within 30 days before the beginning of any enrollment period.
  (2) Submit a copy of the contract used to enroll participants.
  (3) The EMS provider shall maintain a current file of all advertising for the service. Submit a copy of all advertising used to promote the subscription service within 30 days before the beginning of any enrollment period.
  (4) Comply with all state and federal regulations regarding billing and reimbursement for participants in the subscription service.
  (5) Provide evidence of financial responsibility by:
    (A) obtaining a surety bond payable to the department in an amount equal to the funds to be subscribed. The surety bond must be on a department bond form and be issued by a company licensed by or eligible to do business in the State of Texas; or
    (B) submitting satisfactory evidence of self-insurance an amount equal to the funds to be subscribed if the provider is a function of a governmental entity.
  (6) Not deny emergency medical services to non-subscribers or subscribers of non-current status.
  (7) Be reviewed at least every year; and the subscription program may be reviewed by the department at any time.
  (8) Furnish a list after each enrollment period with the names, addresses, dates of enrollment of each subscriber, and subscription fee paid by each subscriber.
  (9) Furnish the department beginning and ending dates of enrollment period(s). Subscription service period shall not exceed one year. Subscribers shall not be charged more than a prorated fee for the remaining subscription service period that they subscribe for.
  (10) Furnish the department with the total amount of funds collected each year.
  (11) Not offer membership nor accept members into the program who are Medicaid clients.
(n) Responsibilities of the EMS provider. During the license period, the EMS provider's responsibilities shall include:
  (1) assuring that all response-ready and in-service vehicles are available 24 hours a day and seven days a week, maintained, operated, equipped and staffed in accordance with the requirements of the provider's license, to include staffing, equipment, supplies, required insurance and additional requirements per the current EMS provider's medical director approved protocols and policies;
  (2) each EMS provider shall develop, implement, maintain, and evaluate an effective, ongoing, system-wide, data-driven, interdisciplinary quality assessment and performance improvement program. The program shall be individualized to the provider and shall, at a minimum, include:
    (A) the standard of patient care as directed by the medical director's protocols and medical director input into the provider's policies and standard operating procedures;
    (B) a complaint management system;
    (C) monitoring the quality of patient care provided by the personnel and taking appropriate and immediate corrective action to insure that quality of care is maintained in accordance with the existing standards of care and the provider medical director's signed, approved protocols;
    (D) the program shall include, but not be limited to, an ongoing program that achieves measurable improvement in patient care outcomes and reduction of medical errors;
  (3) provide an attestation or provide documentation that its management staff will or continue to participate in the local regional advisory council;
  (4) when an air ambulance is initiated through any other method than the local 911 system the air service providing the air ambulance is required to notify the local 911 center or the appropriate local response system for the location of the response at time of launch. This would not include interfacility transports or schedule transports;
  (5) ensuring that all personnel are currently certified or licensed by the department;
  (6) assuring that all personnel, when on an in-service vehicle or when on the scene of an emergency, are prominently identified by, at least, the last name and the first initial of the first name, the certification or license level and the EMS provider's name. A provider may utilize an alternative identification system in incident specific situations that pose a potential for danger if the individuals are identified by name;
  (7) assuring the confidentiality of all patient information is in compliance with all federal and state laws;
  (8) assuring that Informed Treatment/Transport Refusal forms are signed by all persons refusing service, or documenting incidents when a signed Informed Treatment/Transport Refusal form cannot be obtained;
  (9) assuring that patient care reports are completed accurately for all patients and meet standards as outlined in 25 Texas Administrative Code, Chapter 103;
  (10) assuring that patient care reports are provided to facilities receiving the patient:
    (A) whenever operationally feasible, the report shall be provided to the receiving facility at the time the patient is delivered or a full written or computer generated report shall be delivered to the facility within 24 hours of the delivery of the patient,
    (B) if in a response-pending status, an abbreviated documented report shall be provided at the time the patient is delivered and a completed written or computer generated report shall be delivered to the facility within 24 hours of the delivery of the patient;
    (C) the abbreviated report shall document, at a minimum, the patient's name, patient's condition upon arrival at the scene; the prehospital care provided; the patient's condition during transport, including signs, symptoms, and responses to treatment during the transport; the call initiation time; dispatch time; scene arrival time; scene departure time; hospital arrival time; and, the identification of the ambulance staff; and
    (D) in lieu of subparagraph (C) of this paragraph, personnel may follow the Regional Advisory Council's process for providing abbreviated documentation to the receiving facility.
  (11) assuring that all pharmaceuticals are stored according to conditions specified in the pharmaceutical storage policy approved by the EMS provider's medical director;
  (12) assuring that staff completes a readiness inspection as written by the EMS provider's policy;
  (13) assuring that there is a preventive maintenance plan for vehicles and equipment.
  (14) assuring that staff has reviewed policies and procedures as approved by the EMS Provider and the EMS Provider Medical Director;
  (15) Maintenance of medical reports.
    (A) A licensed EMS provider shall maintain adequate medical reports of a patient for a minimum of seven years from the anniversary date of the date of last treatment by the EMS provider.
Cont'd...
(B) If a patient was younger than 18 years of age when last treated by the provider, the medical reports of the patient shall be maintained by the EMS provider until the patient reaches age 21 or for seven years from the date of last treatment, whichever is longer.
    (C) An EMS provider may destroy medical records that relate to any civil, criminal or administrative proceeding only if the provider knows the proceeding has been finally resolved.
    (D) EMS providers shall retain medical records for a longer length of time than that imposed herein when mandated by other federal or state statute or regulation.
    (E) EMS providers may transfer ownership of records to another licensed EMS provider only if the EMS provider, in writing, assumes ownership of the records and maintains the records consistent with this chapter.
    (F) Destruction of medical records shall be done in a manner that ensures continued confidentiality.
    (G) At the time of initial licensing and at each license renewal, the EMS provider and medical director must attest or provide documentation to the department a plan for the going out of business, selling, transferring the business to ensure the maintenance of the medical record as outlined in subparagraph (E) of this paragraph.
    (H) The emergency medical services provider must maintain all patient care records in the physical location that is the provider's primary place of business, unless the department approves an alternate location.
  (16) assuring that all requested patient records are made promptly available to the medical director, hospital or department when requested;
  (17) assuring that current protocols, equipment, supply and medication lists, and the correct original Vehicle Authorization at the appropriate level are maintained on each response-ready vehicle;
  (18) monitoring and enforcing compliance with all policies and protocols;
  (19) assuring provisions for the appropriate disposal of medical and/or biohazardous waste materials;
  (20) assuring ongoing compliance with the terms of first responder agreements;
  (21) assuring that all documents, reports or information provided to the department and hospital are current, accurate and complete;
  (22) assuring compliance with all federal and state laws and regulations and all local ordinances, policies and codes at all times;
  (23) assuring that all response data required by the department is submitted in accordance with §103.5 of this title (relating to Reporting Requirements for EMS Providers);
  (24) assuring that, whenever there is a change in the EMS provider's name or the service's operational assumed name, the printed name on the vehicles are changed accordingly within 30 days of the change;
  (25) assuring that the department is notified within 30 business days whenever:
    (A) a vehicle is sold, substituted or replaced;
    (B) there is a change in the level of service;
    (C) there is a change in the declared service area as written on an initial or renewal application;
    (D) there is a change in the official business mailing address;
    (E) there is a change in the physical location of the business and/or substations;
    (F) there is a change in the physical location of patient report file storage, to assure that the department has access to these records at all times; and
    (G) there is a change of the administrator of record.
  (26) assuring that when a change of the medical director has occurred the department is notified within one business day;
  (27) develop, implement and enforce written operating policies and procedures required under this chapter and/or adopted by the licensee. Assure that each employee (including volunteers) is provided a copy upon employment and whenever such policies and/or procedures are changed. A copy of the written operating policies and procedures shall be made available to the department on request. Policies at a minimum shall adequately address:
    (A) personal protective equipment;
    (B) immunizations available to staff;
    (C) infection control procedures;
    (D) management of possible exposure to communicable disease;
    (E) emergency vehicle operation;
    (F) contact information for the designated infection control officer for whom education based on U.S. Code, Title 42, Chapter 6A, Subchapter XXIV, Part G, §300ff- 136 has been documented.
    (G) credentialing of new response personnel before being assigned primary care responsibilities. The credentialing process shall include as a minimum:
      (i) a comprehensive orientation session of the services, policies and procedures, treatment and transport protocols, safety precautions, and the quality management process; and
      (ii) an internship period in which all new personnel practice under the supervision of, and are evaluated by, another more experienced person.
    (H) appropriate documentation of patient care; and
    (I) vehicle checks, equipment, and readiness inspections;
    (J) the security of medications, fluids and controlled substances in compliance with local, state and federal laws or rules.
  (28) assuring that manufacturers' operating instructions for all critical patient care electronic and/or technical equipment utilized by the provider are available for all response personnel;
  (29) assuring that the department is notified within five business days of a collision involving an in-service or response ready EMS vehicle that results in vehicle damage whenever:
    (A) the vehicle is rendered disabled and inoperable at the scene of the occurrence; or
    (B) there is a patient on board.
  (30) assuring that the department is notified within one business day of a collision involving an in-service or response ready EMS vehicle that results in vehicle damage whenever there is personal injury or death to any person;
  (31) maintaining motor vehicle liability insurance as required under the Texas Transportation Code;
  (32) maintaining professional liability insurance coverage in the minimum amount of $500,000 per occurrence, with a company licensed or deemed eligible by the Texas Department of Insurance to do business in Texas in order to secure payment for any loss or damage resulting from any occurrence arising out of, or caused by the care, or lack of care, of a patient;
  (33) insuring continuous coverage for the service area defined in documents submitted with the EMS provider application;
  (34) responding to requests for assistance from the highest elected official of a political subdivision or from the department during a declared emergency or mass casualty situation according to national, state, regional and/or local plans, when authorized;
  (35) providing written notice to the department, RAC and Emergency Medical Task Force, if the EMS provider will make staff and equipment available during a declared emergency or mass casualty situation, for a state or national mission, when authorized;
  (36) assuring all EMS personnel receive continuing education on the provider's anaphylaxis treatment protocols. The provider shall maintain education and training records to include date, time, and location of such education or training for all its EMS personnel;
  (37) immediately notify the department in writing when operations cease in any service area;
  (38) assure that all patients transported by stretcher must be in a department authorized EMS vehicle; and
  (39) develop or adopt and then implement policies, procedures and protocols necessary for its operations as an EMS provider, and enforce all such policies, procedures and protocols.
(o) License renewal process.
  (1) It shall be the responsibility of the provider to request license renewal application information.
  (2) EMS providers shall submit a completed application, all other required documentation and a nonrefundable license renewal fee, no later than 90 days prior to the expiration date of the current license.
    (A) When a complete application is received by the department 90 or more days prior to the expiration date of the current license that is to be renewed, the applicant shall submit a nonrefundable application fee of $400 per provider plus $180 for each EMS vehicle.
    (B) When a complete application is received by the department 60 or more days, but less than 90 days prior to the expiration date of the current license that is to be renewed, the applicant shall submit a nonrefundable application fee of $450 per provider plus $180 for each EMS vehicle.
Cont'd...
(C) When a complete application is received by the department less than 60 days prior to the expiration of the current license, the applicant shall submit a nonrefundable application fee of $500 per provider plus $180 for each EMS vehicle.
    (D) If the application for renewal is received by the department after the expiration date of the current license, it is deemed to be untimely filed and that license expires on its expiration date. The EMS provider will be required to file a new initial application and follow the initial application process.
    (E) An EMS provider may not operate after its license has expired.
(p) Provisional License. The department may issue an EMS provisional license if an urgent need exists in a service area when the department finds that the applicant is in substantial compliance with the provisions of this section and if the public interest would be served. A provisional license shall be effective for no more than 30 days from the date of issuance.
  (1) An EMS provider may apply for a provisional license by submitting a written request and a nonrefundable fee of $30.
  (2) A provisional license issued by the department may be revoked at any time by the department, with written notice to the provider, when the department finds that the provider is failing to provide appropriate service in accordance with this section or that the provider is in violation of any of the requirements of this chapter.
(q) Advertisements.
  (1) Any advertising by an EMS provider shall not be misleading, false, or deceptive. When an EMS provider advertises in Texas and/or conducts business in Texas by regularly transporting patients from, or within Texas, the provider shall be required to have a Texas EMS Provider License.
  (2) An EMS provider shall not advertise levels of patient care which it cannot provide at all times. The provider shall not use a name, logo, art work, phrase or language that could mislead the public to believe a higher level of care is being provided.
  (3) An EMS provider that has more than five paid staff, but is composed of at least 75% volunteer EMS personnel may advertise as a volunteer service.
(r) Surveys/Inspections and Investigations.
  (1) The department may conduct scheduled or unannounced on-site inspection or investigation of a provider's vehicles, office(s), headquarter(s) and/or station(s) (hereinafter operations), at any reasonable time, including while services are being provided, to ensure compliance with Health and Safety Code, Chapter 773 and this chapter.
  (2) An applicant or licensee, by applying for or holding a license, consents to entry and inspection or investigation of any of its operations by the department, as provided for by the Health and Safety Code, Chapter 773 and this chapter.
  (3) Department's inspections or investigations to evaluate an EMS provider's compliance with the requirements of the Health and Safety Code, Chapter 773 and this chapter, may include:
    (A) initial, prelicensure and change in status inspections for the issuance of a new license;
    (B) routine inspection conducted at the departments' discretion or prior to renewal;
    (C) follow-up on-site inspection, conducted to evaluate implementation of a plan of correction for deficiencies cited during a department investigation or inspection;
    (D) a complaint investigation, conducted in response to a report or complaint, as described in subsection (u) of this section, relating to complaint investigations; and
    (E) an inspection to determine if a person, company, or organization is offering or providing EMS service(s) without a license, or to determine if EMS vehicles are being staffed by persons who do not hold Texas EMS certification or license.
  (4) The provider and medical director shall cooperate with any department investigation or inspection, and shall, consistent with applicable law, permit the department to examine the provider's grounds, buildings, books, records and other documents and information maintained by or on behalf of the provider, that are necessary to evaluate compliance with applicable statutes, rules, plans of correction and orders with which the EMS provider is required to comply. The EMS provider shall permit the department, consistent with applicable law, to interview members of the governing authority, personnel and patients.
  (5) The EMS provider shall, consistent with applicable law, permit the department to copy or reproduce, or shall provide photocopies to the department of any requested records or documents. If it is necessary for the department to remove records or other information (other than photocopies) from the provider's premises, the department will provide the EMS provider's governing authority or designee with a written statement of this fact, describing the information being removed and when it is expected to be returned. The department will make a reasonable effort, consistent with the circumstances, to return the records the same day.
  (6) The department will hold an entrance conference with the EMS provider, governing authority or designee before beginning the inspection or investigation, to explain, consistent with applicable law, the nature, scope and estimated time schedule of the inspection or investigation.
  (7) Except for a complaint investigation or a follow-up visit, an inspection will include an evaluation of compliance with the Health and Safety Code, Chapter 773 and the rules of this chapter. During the inspection, the department representative will, unless otherwise provided for by law, inform the EMS provider's governing authority or designee of the preliminary findings and give the provider a reasonable opportunity to submit additional facts or other information to the department representative in response to those findings.
  (8) When the inspection is complete, the department will hold an exit conference with the provider, unless otherwise provided for by law, to inform the provider, to the extent permitted by law, of any preliminary findings of the inspection or investigation and to give the EMS provider the opportunity to provide additional information regarding the deficiencies cited. If no deficiencies are identified at the time of inspection, a statement indicating this fact may be left with the EMS provider's governing authority or designee. Such a statement does not constitute a department finding or certification that the facility is in compliance.
  (9) If deficiencies are cited:
    (A) the department will provide the EMS provider's administrator of record and medical director with a written deficiency report no more than 30 calendar days after the exit conference.
    (B) The EMS provider's governing authority, designee, or person in charge at the time shall sign an acknowledgement of the inspection and receipt of the written deficiency report and return it to the department. The signature does not indicate the EMS provider's agreement with, or admission to the cited deficiencies unless the agreement or admission is explicitly stated.
    (C) No later than 30 calendar days after the EMS provider's receipt of the deficiency report, the EMS provider shall return a written plan of correction to the department for each deficiency, including time frames for implementation, together with any additional evidence of compliance the EMS provider may have, regarding any cited deficiency. The department will determine if the written plan of correction and proposed timeframes for implementation are acceptable. If the plan is not acceptable, the department will notify the provider in writing no later than 30 days after receipt and request a modified plan. The EMS provider shall modify and resubmit the plan of correction no later than 30 calendar days after the EMS provider's receipt of the request. The EMS provider shall correct the identified deficiencies and submit documentation to the department verifying completion of the corrective action within the timeframes set forth in the plan of correction accepted by the department, or as otherwise specified by the department. The provider will be deemed to have received the deficiency report or other department correspondence mailed under this subparagraph three days after mailing.
    (D) Regardless of the EMS provider's compliance with this subsection, the department's acceptance of the provider's plan of correction, or the provider's utilization of an informal compliance group review under paragraph (10) of this subsection, the department may, at any time, propose to take action as appropriate under §157.16 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation, Denial of a Provider License or Administrative Penalties).
Cont'd...
(10) The department inspector will inform the provider's chief executive officer, designee, or person in charge at the time of the inspection, of the provider's right to an informal compliance group review, when there is disagreement with deficiencies cited by the inspector or investigator, that the provider was unable to resolve through submission of information to the inspector or additional information bearing on the deficiencies cited.
  (11) The department shall refer issues and complaints relating to the conduct or actions by licensed professionals to their appropriate licensing boards.
  (12) All initial applicants and their medical director shall be required to have an initial compliance survey by the department that evaluates all aspects of the applicant's proposed operations including clinical care components and an inspection of all vehicles prior to the issuance of a license.
  (13) At renewal, randomly, or in response to a complaint, the department may conduct an unannounced compliance survey that includes inspection of a provider's vehicles, operations and/or records to ensure compliance with this title at any time, including nights or weekends.
  (14) If a re-survey/inspection to ensure correction of a deficiency is conducted, the provider shall pay a nonrefundable fee of $30 per vehicle needing a re-inspection.
(s) Specialty Care Transports. A Specialty Care Transport is defined as the interfacility transfer by a department licensed EMS provider of a critically ill or injured patient requiring specialized interventions, monitoring and/or staffing. To qualify to function as a Specialty Care Transport the following minimum criteria shall be met:
  (1) Qualifying Interventions:
    (A) patients with one or more of the following IV infusions: vasopressors; vasoactive compounds; antiarrhythmics; fibrinolytics; tocolytics; blood or blood products and/or any other parenteral pharmaceutical unique to the patient's special health care needs; and
    (B) one or more of the following special monitors or procedures: mechanical ventilation; multiple monitors; cardiac balloon pump; external cardiac support (ventricular assist devices, etc); any other specialized device, vehicle or procedure unique to the patient's health care needs.
  (2) Equipment. All specialized equipment and supplies appropriate to the required interventions shall be available at the time of the transport.
  (3) Minimum Required Staffing. One currently certified EMT-Basic and one currently certified or licensed paramedic with the additional training as defined in paragraph (4) of this subsection; or, a currently certified EMT-Basic and a currently certified or licensed paramedic accompanied by at least one of the following: a Registered Nurse with special knowledge of the patient's care needs; a certified Respiratory Therapist; a licensed physician; or, any other licensed health care professional designated by the transferring physician.
  (4) Additional Required Education and Training for Certified/Licensed Paramedics: Evidence of successful completion of post-paramedic education, training and appropriate periodic skills verification in management of patients on ventilators, 12 lead EKG and/or other critical care monitoring devices, drug infusion pumps, and cardiac and/or other critical care medications, or any other specialized procedures or devices determined at the discretion of the EMS provider's medical director.
(t) For all initial applications and renewal applications, the department is authorized to collect subscription and convenience fees, in amounts determined by the Texas Online Authority, to recover costs associated with the initial application and renewal application processing through Texas Online.
(u) Complaint Investigations.
  (1) Upon request, all licensed EMS Providers shall make available for a patient or its legal guardian a written statement supplied by the department, identifying the department as the responsible agency for conducting EMS provider and EMS personnel complaint investigations. The statement shall inform persons that they may direct a complaint to the Department of State Health Services, EMS Compliance Group, by phone, or by email. The statement shall provide the most current contact information, including the appropriate department group, address, local and toll-free telephone number, and email address for filing a complaint.
  (2) The department evaluates all complaints made against EMS providers and/or EMS personnel. Any complaint submitted to the department shall be submitted by telephone, electronically, or in writing, using the department's current contact information for that purpose, as described in paragraph (1) of this subsection.
  (3) The department will document, evaluate and prioritize complaints and information received, based on the seriousness of the alleged violation and the level of risk to patients, personnel and/or the public.
    (A) Allegations determined to be within the department's regulatory jurisdiction relating to emergency medical services are authorized for investigation under this chapter. Complaints received that are outside the department's jurisdiction may be referred to another appropriate agency for response.
    (B) The investigation is conducted on-site, by telephone and/or through written correspondence.
  (4) The department conducts a prompt and thorough investigation of all reports or complaint allegations that may pose a threat of harm to the health and safety of patients or participants. Reports or complaints received by the department concerning alleged abuse, neglect and exploitation will be addressed in accordance with Human Resources Code, Chapter 48 and Family Code, §261.101(d).
  (5) The department evaluates complaint allegations that do not pose a significant risk of harm to patients. Based on the nature and severity of the alleged incident, the department determines whether to investigate the complaint directly or to require the provider to conduct an internal investigation and submit its findings and supporting evidence to the department.
    (A) The findings of an EMS provider's internal investigation will be reviewed by the department and may result in an additional investigation by the department, a request for a plan of correction to be completed by the provider in accordance with subsection (q) of this section (relating to inspections and investigations) and/or a proposal to take action against the provider under §157.16 of this title.
    (B) The EMS provider under investigation shall provide department staff access to all documents, evidence and individuals related to the alleged violation, including all evidence and documentation relating to any internal investigations.
  (6) Once an internal EMS provider investigation and/or department investigation is complete, the department reviews the evidence from the investigation to evaluate whether the evidence substantiates the complaint and what corrective action, if any, is needed.

Source Note: The provisions of this §157.11 adopted to be effective August 17, 2008, 33 TexReg 6395; amended to be effective August 10, 2014, 39 TexReg 5951; amended to be effective February 12, 2017, 42 TexReg 430; amended to be effective September 13, 2022, 47 TexReg 5484