EMS Provider Surveys

Background

The Texas Department of State Health Services (DSHS) has statutory authority pursuant to Texas Health and Safety Code Chapter 773, including Section 773.0611,  and the licensing rules under 25 Texas Administrative Code Chapter 157, including Section 157.11(r),  to conduct inspections and surveys of licensed EMS providers and their licensed vehicles. To ensure compliance, the DSHS EMS Compliance staff has conducted initial vehicle inspections and provider surveys.


In 2014, DSHS began a systematic effort to inspect ambulances during the licensing period, our goal, subject to available resources, was to inspect all licensed ambulances at least once every three years, across the state. We have begun that same effort for EMS provider surveys. The inspection frequency was intermittent in the past, due to limited available resources DSHS provided initial surveys using the initial provider survey checklist, the latest version implemented in 2011. The checklist was also available for providers to use as part of their own self-evaluations and quality assurance efforts.

Recently, due to several factors including implementation of SB 8, the CMS moratorium, and available resources, we have implemented a provider survey workload plan that should result in each of licensed EMS provider consistently being surveyed at least every three years. This survey will concentrate on the provider's compliance with rule section 157.11(n). Although DSHS has the authority to conduct unannounced surveys, most surveys will be announced and scheduled with the provider by the DSHS EMS Program staff. Such scheduling allows DSHS to better plan and manage our workload across the state, and helps the provider be prepared for the survey and have the right people participate in the survey, especially the administrator and medical director. The provider will be asked to provide certain documents to DSHS, as well as complete a self-evaluation document.  

A deficiency report and plan of correction process will be utilized should the survey identify deficiencies; however, a failure to promptly correct, serious, or repeat non-compliance may result in DSHS considering state enforcement action.  While several denials of initials have been proposed due to survey findings, the providers eventually were licensed. So far, DSHS has not proposed other enforcement actions such as revocation or administrative penalties against a licensed provider for non-compliance survey findings. The DSHS EMS Program regional offices are your best resource for technical assistance regarding the survey process. The contact information for the Group or field offices is available at: /emstraumasystems/regions.shtm.

The initial survey checklist and the compliance survey checklist are available as PDF documents on the DSHS EMS website: /emstraumasystems/provfro.shtm

Frequently asked questions