Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 170.000 - Emergency Medical Services System › Section 170.300 - Affiliation Agreements

Current through Register 1525, July 5, 2024
(A) To be licensed
			 to provide ALS services, each ambulance or EFR service must have a current
			 written contract, called an affiliation agreement, with one or more hospitals
			 licensed by the Department to provide medical control, in accordance with
			 105
			 CMR 170.300(D). This
			 agreement shall contain a reasonable and effective plan for medical control and
			 include the following features:
(1) Treatment
			 protocols and point-of-entry plans using regional guidelines that are in
			 conformance with the Statewide Treatment Protocols, and other relevant
			 regulations, policies and administrative requirements of the
			 Department;
(2) Designation of an
			 affiliate hospital medical director, who shall have authority over the clinical
			 and patient care aspects of the affiliated EMS service including, but not
			 limited to, the authorization to practice of its EMS personnel;
(3) Provision of on-line medical direction in
			 accordance with the Statewide Treatment Protocols 24 hours per day, seven days
			 per week, by a hospital-based physician;
(4) Operation of an effective quality
			 assurance/quality improvement (QA/QI) program coordinated by the affiliate
			 hospital medical director and with participation of on-line medical direction
			 physician(s) and service medical director, if different from the affiliate
			 hospital medical director, that includes, but is not limited to, regular review
			 of patient care reports and other statistical data pertinent to the EMS
			 service's operation, in accordance with the hospital's QA/QI standards and
			 protocols;
(5) Operation of a
			 program for skill maintenance and review for EMS personnel;
(6) Ensuring EMS personnel have access to
			 remediation, training and retraining, as necessary, under the oversight of the
			 affiliate hospital medical director or his or her designee;
(7) Regular consultation between medical and
			 nursing staffs and EMS personnel providing ALS services including, but not
			 limited to, attendance at morbidity and mortality rounds and chart
			 reviews;
(8) A procedure by which a
			 physician can maintain recorded direct verbal contact with the EMS personnel
			 regarding a particular patient's condition and order, when appropriate, the
			 administration of a medication or treatment for a patient, to which such
			 physician or his or her designee shall sign the patient care report documenting
			 the patient's care and transport by the EMS personnel;
(9) Policies and procedures for obtaining
			 medications, in accordance with the level of licensure of the EMS service, from
			 the hospital's pharmacy;
(10) A
			 procedure by which the service shall notify its affiliate hospital medical
			 director within 72 hours of Department action against any EMT's or EFR's
			 certification (denial, suspension, revocation or refusal to renew
			 certification), or other Department disciplinary action (letter of censure,
			 letter of clinical deficiency, advisory letter) against any EMS personnel
			 employed by the service; and
(11)
			 If the service has more than one affiliation agreement, in accordance with
			 105
			 CMR 170.300(D), the identity
			 of all hospitals with which the service has affiliation agreements and policies
			 and procedures that set forth the duties and responsibilities of each affiliate
			 hospital.