333-250-0265 Policies and Procedures (1) A licensed ambulance service must have written policies and procedures applicable to the area of operation to carry out daily ambulance service operations including, but not limited to: (a) Work practice controls and training requirements for bloodborne pathogens and hazardous material as required by the Department of Consumer and Business Services, Oregon Occupational Safety and Health Division; (b) Storage and security of medications including controlled substances if authorized by the emergency medical services (EMS) medical director as required by the Oregon Board of Pharmacy and the US Drug Enforcement Administration in accordance with OAR 333-250-0300; (c) Identification, storage and security of all medications, fluids and controlled substances that are deteriorated, outdated, misbranded, adulterated or otherwise unfit for use that are readily identified as defective and stored in a separate location from usable products. Security procedures must be the same as for usable supplies; (d) Destruction of outdated medications including controlled substances if authorized by the EMS medical director as required by the Oregon Board of Pharmacy and the US Drug Enforcement Administration; (e) Identification and storage of malfunctioning patient care equipment clearly marked "out-of-service" to ensure that defective equipment will not be used, if applicable; (f) Employee, volunteer or ambulance-based clinician notification requirements to the licensed ambulance service when an employee, volunteer or ambulance-based clinician is impaired by excessive fatigue, illness, injury or other factors that may reasonably be anticipated to constitute a threat to the health and safety of patients or the public; (g) Reporting of suspected child abuse as required in ORS 419B.005 through 419B.050; (h) Reporting of suspected elder abuse as required in ORS 124.050 through 124.095; (i) Patient rights in accordance with OAR 333-250-0330; (j) Providing secure transport for patients in custody in accordance with OAR chapter 309, division 033, if the licensed ambulance service has been authorized to perform this service; (k) Operation of an ambulance for both emergency and non-emergency situations; (l) Vehicle cleanliness standards including frequency of cleaning and cleaning required after each patient transport in accordance with OAR 333-255-0095 ; (m) Removal of an ambulance from service when the mechanical condition of an ambulance is sufficiently unreliable so as to endanger or potentially endanger the health, safety, or welfare of a patient or crew member; (n) Managing a mechanical breakdown including repairing or replacing a damaged tire or wheel when the ambulance is in operation; (o) Actions necessary when an ambulance is involved in a collision, including the submission of a legible copy of the Driver and Motor Vehicles (DMV), Oregon Traffic Collision and Insurance Report to the Oregon Health Authority (Authority) within 10 business days of the collision; (p) Release of continuing education records completed by an EMS provider or employee through the licensed ambulance service in a verifiable format to a requesting party within five business days of the request; (q) A quality assessment and performance improvement process in accordance with the requirements under OAR 333-250-0320; (r) Release and destruction of both paper and electronic patient care reports in accordance with OAR 333-250-0310; and (s) If the agency sponsors an EMS provider seeking licensure as a Transitional Paramedic, requirements necessary for the agency to sponsor the Transitional Paramedic applicant including but not limited to: (A) Providing the necessary information prescribed by the Authority and specified under OAR 333-265-0027 to the Transitional Paramedic applicant; (B) Requiring a Transitional Paramedic to submit accurate, annual reports to the ambulance service on the status of meeting the requirement under OAR 333-265-0025(8)(a)(C); (C) Requiring a Transitional Paramedic to notify the ambulance service of any request to the Authority seeking hardship status in accordance with OAR 333-265-0027 and the Authority’s approval if applicable; and (D) Steps that will be taken or resources given to ensure the success of a Transitional Paramedic in obtaining a Paramedic license. (2) The licensed ambulance service must have a process in place to ensure that employees, volunteers, ambulanced-based clinicians, agents and EMS medical directors: (a) Have access to current policies and procedures; (b) Have access to state, federal and local rules and regulations governing the operation of a licensed ambulance service; and (c) Are informed of changes to policies or procedures. Statutory/Other Authority: ORS 682.017 & 682.068 Statutes/Other Implemented: ORS 682.017 - 682.117 & 682.991 History: PH 19-2025, amend filed 09/24/2025, effective 01/01/2026 PH 52-2023, amend filed 11/07/2023, effective 12/01/2023 PH 54-2021, minor correction filed 10/04/2021, effective 10/04/2021 PH 7-2017, f. & cert. ef. 3-21-17