EMS Agency and Vehicle Surveillance and Inspections

Bureau of EMS Policy Statement
Policy Statement # 10-03
Date January 15, 2009
Subject Re: EMS Agency and Vehicle Surveillance and Inspections
Supercedes/Updates 89-05, 02-03

I) Introduction

In an effort to ensure compliance with New York State Public Health Law and the associated Codes, Rules and Regulations and Policy Statements, the Department of Health is authorized to conduct full service inspections/surveys as well as individual vehicle inspections. The Department may inquire into the operation of ambulance services and advanced life support first response services and conduct periodic inspections of facilities, communication services, vehicles, methods, procedures, materials, staff and equipment.

II) Full Service Inspections:

a) Department of Health Bureau of EMS Surveillance:

The Purpose of a full service inspection is to ensure that an ambulance service or Advanced Life Support First Response (ALSFR) agency is in compliance with all the applicable laws, regulations and department policies regarding the safe and efficient operation of the EMS agency. In conducting these inspections department representatives assist agencies in achieving the goal of not only overall compliance but also improved quality of care delivered to patients.

b) Ambulance Services;

Ambulance services are required to comply with the provisions set forth in Part 800 of Title 10 NYCRR. This includes Part 800.21 General Requirements.

During a full ambulance agency inspection, representatives from the Department may inspect any of the items outlined in Part 800.21 including, but not limited to:

  • Personnel files
  • Training records
  • Incident reports
  • Prehospital Care Reports
  • Agency Policies (Including all policies required in Part 800.21(p))
  • Mutual Aid Plans
  • Hazardous Materials Plans
  • Multiple Casualty Incident Plans
  • Ambulances
  • Emergency Ambulance Service Vehicles (EASV) including personally owned vehicles operated as EASVs as authorized by the agency
  • Buildings and facilities for such items as the proper storage of supplies and equipment and the proper disposal of regulated materials
  • Equipment (including all requirements listed in Part 800.22-800.25)
  • Vehicle check sheets and maintenance records
  • Personnel Rosters.

c) Advanced Life Support - First Response Agencies:

Advanced Life Support First Response (ALS FR) agencies are required to comply with the provisions set forth in Part 800 of Title 10 NYCRR and applicable Department of Health, Bureau of Emergency Medical Services Policy Statements.

During an ALS FR agency inspection, representatives from the Department may inspect any of the items outlined in that policy statement including but not limited to:

  • Personnel files
  • Training records
  • Incident reports
  • Prehospital Care Reports
  • Agency Policies
  • Mutual Aid Plans
  • Hazardous Materials Plans
  • Multiple Casualty Incident Plans
  • All vehicles operated as emergency vehicles by the agency
  • Buildings and facilities for such items as the proper storage of supplies and equipment and the proper disposal of regulated materials.

d) Controlled Substances Licensees:

Any service granted a license to possess and administer controlled substances in accordance with Article 33 and Part 80 of Title 10 NYCRR, shall be subject to inspection of all records, stock, sub-stock, security standards and for compliance with the operations plan submitted by the agency and approved by the Department.

e) Quality Improvement Program:

Inspections of either an ambulance service or ALS FR agency may also include records pertaining to the establishment of, or participation in, a Quality Improvement Program as required in §3006 of the Public Health Law.

III) Vehicle Inspections:

Inspections of emergency medical services vehicles may be conducted by representatives of the Department of Health anytime the vehicles are in service. For a vehicle to be considered "Out of Service" it should be in compliance with Department of Health Bureau of Emergency Medical Services Policy.

a) Spot/Quick Check;

Vehicle inspections may, at the discretion of the Department representative, consist of a "Quick Check" or a full vehicle inspection.

The "Quick Check" attempts to verify twenty-four (24) items of the required equipment and supplies found in Part 800 of the State Health Code. These items are generally used to treat patients suffering from life threatening illness or injury. Any ambulance found missing these minimum standards may be removed from service, and a full vehicle inspection conducted.

b) Complete Vehicle Inspection;

Any vehicle operated by an ambulance service as an ambulance shall be required to be in complete compliance with the applicable sections of 10 NYCRR Part 800, unless otherwise authorized by the Commissioner pursuant to Part 800.25 or 800.27.

Any vehicle operated by an ambulance service as an Emergency Ambulance Service Vehicle (EASV) must be in compliance with Parts 800.21, 800.23 and 800.26. This includes personally owned vehicles authorized as EASVs by the agency.

Any vehicle operated by an Advanced Life Support First Response Service as a first response vehicle must be in complete compliance with Parts 800.21, 800.23, 800.26 and Department of Health Bureau of Emergency Medical Services policies.

All vehicles operated as emergency vehicles must be in compliance with the applicable sections of the NYS Vehicle and Traffic Law.

Any vehicle that fails an inspection may be placed out of service by the Department representative conducting the inspection. The failure may result in the issuance of a Notice of Violation or a Statement of Deficiencies. In both cases, the service will be required to submit plans in writing that address the deficiencies and steps taken to correct the identified violations.

In an effort to provide the most effective care in the prehospital environment, the Bureau of EMS encourages agencies to operate with more than the minimally required supplies and equipment.

The items required by Part 800 and Bureau of EMS policy statements are the minimum requirements for the operation of an EMS service. There are many additional policies that agencies may implement for productive operation. There are additional supplies and equipment that a service may wish to utilize to enhance patient care. Each agency is encouraged to evaluate their operation to determine whether additional equipment and supplies would be appropriate for use in their EMS system. However, medical equipment and supplies should be in accordance with state and regional treatment protocols, the scope of practice of the service and all applicable federal, state and regional guidelines. Should items inappropriate for the authorized level of care be found in agency vehicles, the agency may be subject to enforcement action.

IV) Additional information:

In addition to the Bureau of EMS Policy statements already listed, EMS agency operators are encouraged to refer to the Bureau of EMS Policy Statement page at: http://www.health.state.ny.us/professionals/ems/policy/policy.htm for policies that include items subject to inspection by the Department.

Issued and Authorized by Lee Burns, Acting Director, Bureau of Emergency Medical Services