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: http://www.dshs.state.tx.us/emstraumasystems/regions.shtm.

The initial survey checklist and the compliance survey checklist are available as PDF documents on the DSHS EMS website: http://www.dshs.state.tx.us/emstraumasystems/provfro.shtm


Frequently asked questions

  1. Are the EMS Provider Surveys new?
  2. Why does DSHS conduct EMS Provider Surveys?
  3. How will we know when it’s time for our survey?
  4. Do we have to wait until its time for our survey before we can begin preparing?
  5. What are some of the most common survey deficiencies that the department finds?
  6. So what happens when deficiencies are found?

     


    1. Are the EMS Provider Surveys new?

    No, DSHS (department) has been conducting these surveys for many years.  The survey has been known by many different names throughout the years – Renewal Survey, Responsibility Survey, Site-Survey, Compliance Survey, etc. but the overall process has remained the same.

    1. Why does DSHS conduct EMS Provider Surveys?

    The department conducts EMS Provider surveys to ensure that the EMS Provider is in compliance with all the different aspects of the Texas Administrative Code (TAC) Rule 157.11.  The survey process allows the Administrator of Record (AOR) and all other administrative and supervisory staff to do a comprehensive “self-study” of their service and become familiar with all the licensing requirements and responsibilities of an EMS Provider.  This survey process also serves as a way for the DSHS EMS Specialist to get to know and understand how each unique EMS Provider operates.  The department strongly recommends that the AOR and the medical director participate and attend the surveys. Rule 157.11 (n) establishes the minimum standards an EMS Provider must meet to be in compliance.  Depending on the EMS Provider, certain policies and procedures may be adopted, implemented and enforced, and those policies and procedures, in addition to the rules, are what the department will survey to and hold the EMS Provider accountable for.  The department will not survey for “best practices.”

    1. How will we know when it’s time for our survey?

    While the department has authority to conduct unannounced surveys, at this time most surveys will be announced approximately 30 days in advance.  An EMS Specialist will send the EMS Provider a notice advising of the upcoming survey along with a copy of the Compliance Survey Checklist and Questionnaire so that the EMS Provider can start preparing by doing their own “self-survey”.

    1. Do we have to wait until it's time for our survey before we can begin preparing?

    The department encourages each EMS Provider to be familiar with all the requirements and responsibilities of TAC Rule 157.11.  You can start working on your “self-survey” and find opportunities for improvement and address any issues identified by using the Compliance Survey Checklist and Questionnaire. 

    1. What are some of the most common survey deficiencies that the department finds?

    1. Lack of a QA Plan that addresses the minimums as per TAC Rule 157.11 (n) (2) (A-D) or a QA Plan exists but is not being utilized or documented. 
    2. No documentation of the EMS Provider’s Anaphylaxis training.
    3. Pharmaceutical storage not in compliance with manufacturer’s and/or FDA recommendations.
    4. No documentation in regards to crewmember Orientation and Internship Period.
    5. EMS Provider is not assuring that data is being reported to the EMS & Trauma Registries.

       6. So what happens when deficiencies are found?

    Upon completion of the survey, an EMS Specialist will have an exit conference with the AOR and discuss any preliminary findings. The Specialist will then discuss the preliminary findings with the Group Manager and a results letter will be sent to the EMS Provider within 5 business days.  If any deficiencies need to be corrected, a Survey Notice will also be sent that further explains the requirements for the EMS Provider to submit an acceptable Plan of Correction.  Upon the receipt by the department of the EMS Provider’s Plan of Correction or anytime thereafter, the department may conduct a follow-up survey to validate or confirm the corrections were made.   The plan of correction process will be the usual procedure utilized should the survey identify non-compliance; however, a failure to promptly correct, serious or repeat non-compliance may result in DSHS considering state enforcement action.

     

     

    Last updated February 1, 2018