BILL ANALYSIS �
AB 1245
Page 1
Date of Hearing: May 3, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1245 (Williams) - As Amended: April 26, 2011
SUBJECT : Emergency medical services.
SUMMARY : Establishes requirements for regulations proposed for
adoption or adopted by the state Emergency Medical Services
Authority (EMSA) relating to Emergency Medical Responders
(EMRs). Specifically this bill:
1)Applies to regulations establishing state approval of an EMR
course that meets or exceeds the United States Department of
Transportation's EMR: Instructional Guidelines and if
completion of the course is a condition for appointment to a
position serving in a public safety capacity to function as an
EMR without an Emergency Medical Technician (EMT)-I, EMT-II,
Advanced EMT or EMT-Paramedic certificate:
2)Requires that prior to appointment the appointing agency
shall:
a) Require the appointee to submit fingerprints and a
request for a state and federal criminal offender record
information search (CORI) and a subsequent arrest
notification report;
b) Requires the appointing agency to verify completion of
the EMR course of instruction; and,
c) Requires the appointing agency to verify that the EMR is
not precluded from appointment, as specified.
EXISTING LAW :
1)Establishes the state EMSA which is responsible for the
coordination and integration of all state activities
concerning emergency medical services (EMS) including
establishing the minimum standards for the policies and
procedures necessary for medical control of the EMS system.
2)Authorizes counties to develop an EMS program and designate a
Local Emergency Medical Services Agency (LEMSA) responsible
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for planning and implementing an EMS system.
3)Establishes the 16-member EMS Commission within the California
Health and Human Services Agency and specifies its membership
and appointing authorities and defines the duties.
4)Requires EMSA to maintain a central registry of EMTs, and to
create EMT certification, recertification, and disciplinary
standards.
5)Requires all EMTs to submit finger prints for a state and
federal level CORI search including subsequent arrest
information.
6)Requires a person to be licensed by EMSA in order to practice
as a paramedic.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the sponsors, the
California Professional Firefighters, the purpose of this bill
is to ensure that anyone in training to be employed or
volunteer in a public safety capacity rendering first aid in
an emergency setting be subject to the same background check
as is required of certificated EMTs. According to the
sponsors, clarification is needed to ensure a consistent
application of the requirement that background checks be
conducted to facilitate greater coordination and oversight
among emergency medical stakeholders and ultimately strengthen
patient care.
2)BACKGROUND . California operates on a two-tiered EMS system.
EMSA is the state lead agency and centralized resource to
oversee emergency and disaster medical services. EMSA is
charged with providing leadership in developing and
implementing local EMS systems throughout California and
setting standards for the training and scope of practice of
various levels of EMS personnel. The EMS Act establishing
this system was intended to transform a haphazard delivery of
prehospital emergency services into a more unified and
coordinated approach. Day-to-day EMS system management is the
responsibility of the local and regional EMS agencies.
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California has 32 local EMS systems that are providing
emergency medical services for California's 58 counties.
Seven regional EMS systems comprised of 33 counties and 25
single county agencies provide the services. Regional systems
are usually comprised of small, more rural, less-populated
counties and single-county systems generally exist in the
larger and more urban counties.
3)PREHOSPITAL EMERGENCY MEDICAL CARE PERSONNEL . EMSA develops
and implements regulations that set training standards and the
scope of practice for emergency medical personnel, EMT-Basic
(EMT-B or EMT, previously EMT-I), Advanced EMTs (AEMT)
(previously EMT-IIs), paramedics, Mobile Intensive Care
Nurses, firefighters, peace officers, and lifeguards. EMTs
and AEMTs are initially certified by a LEMSA according to
guidelines and regulations developed by EMSA, including
criminal background checks. The responsibility for
disciplinary investigations, suspensions and revocations is
shared by the LEMSA, ambulance service employers licensed by
the California Highway Patrol and fire and public safety
agencies.
In 1993 EMSA took over the licensure of paramedics from the
LEMSAs. This program licenses and conducts disciplinary
investigations of paramedics or EMT-Ps. EMSA has the
responsibility to review the license applications to ensure
that licensing requirements are met, including training,
testing, and continuing education, and completion of criminal
background checks for initial paramedic licensure applicants
and for those whose licenses have lapsed for more than a year.
EMSA also investigates and prosecutes complaints regarding
paramedic prehospital care, inappropriate conduct, and other
related issues, including information revealed from the
criminal background checks.
4)UPDATING PERSONNEL PROGRAM STANDARDS . The trend towards an
enhanced role of a state entity and more uniformity has
persisted. AB 2917 (Torrico), Chapter 274, Statutes of 2008,
required EMSA to establish a statewide EMT registry and to
develop standards, guidelines, and regulations for
certification of EMTs and required all EMTs to have a criminal
background check. AB 2917 also established rules for EMT
certification and discipline and for the investigation of
conduct that threatens public health and safety. AB 2917 was
enacted in response to identified failures in the oversight
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and discipline of EMTs. Prior to its passage, numerous
problems had been identified in the media. A series of
articles in the Los Angeles Times (Times) for instance,
reviewed all regulatory actions from 2000 to 2006 statewide
and concluded that there was no coherent system for reporting
problems or processing complaints that could lead to
discipline. They found substantial variation from region to
region. According to a Times article in 2007, a large part of
the problem is the culture in which the emergency response
system developed. It was essentially welded onto fire
departments, which functioned primarily as public safety
providers with a paramilitary tradition, not as medical
caregivers. According to the Times, now, the bulk of what
these departments do is medical response-but their regulatory
standards area still catching up with the rest of the medical
professions.
In July of 2008, EMSA issued "Recommended Guidelines for
Disciplinary Orders and Conditions of Probation" to provide
guidance and uniformity to the local application of an
existing section that lists conduct considered evidence of a
threat to the public health and safety including commission of
certain crimes and acts of gross negligence. EMSA has
continued to update the other regulatory standards.
Regulations relating to EMTs were updated effective October 6,
2010.
5)NATIONAL EMS SCOPE OF PRACTICE MODEL . Paralleling the state's
attempts towards uniformity, consistency, and integration, the
National EMS Scope of Practice Model is part of the National
Highway Traffic Safety Administration (NHTSA) and the Health
Resources and Services Administration implementation of the
EMS Agenda for the Future. According to the NHTSA, it is part
of an integrated, interdependent system, to maximize
efficiency, consistency of instructional quality, and student
competence. According to the NHTSA Website, states following
the National EMS Scope of Practice Model as closely as
possible will increase the consistency of the nomenclature and
competencies of EMS personnel nationwide, facilitate
reciprocity, improve professional mobility, and enhance the
name recognition and public understanding of EMS.
The National EMS Scope of Practice Model defines and describes
four levels of EMS licensure: EMR, EMT, AEMT, and paramedic.
New EMSA regulations took effect January 14, 2011
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transitioning the category of EMT-II to AEMT. Among other
changes, the new regulations expanded the scope of practice
and requires a transition by July 1, 2013 to the use of a
written and skills examination by the National Registry of
Emergency Medical Technicians in place of one administered by
a local training program or a LEMSA.
At the March 23, 2011 meeting of the EMS Commission, the
acting Director of EMSA reported that an EMR Task Force had
been convened to revise the Public Safety First Aid
Regulations, adopt a scope of practice for the Public Safety
First Aid providers, adopt the EMR as a level of EMS responder
and adopt the training requirements and scope of practice for
EMRs. It was further reported that the Task Force recommended
removing EMR from the Public Safety First Aid Chapter of
Regulations and placing it in its own chapter of regulations.
The purpose was to separate the focus on public safety first
aid requirements from the EMR requirements. The director
further reported that the new EMR Regulations will be similar
to the EMT Regulations with respect to training program
approval requirements and will include a scope of practice
consistent with the National Scope of Practice Model. The EMS
Authority is not proposing to require certification or
criminal background checks for the EMR, due to the lack of
statutory authority.
According to NHTSA, the primary focus of the EMR is to
initiate immediate lifesaving care to critical patients who
access the emergency medical system. This individual
possesses the basic knowledge and skills necessary to provide
lifesaving interventions while awaiting additional EMS
response and to assist higher level personnel at the scene and
during transport. Emergency Medical Responders function as
part of a comprehensive EMS response, under medical oversight.
EMRs perform basic interventions with minimal equipment.
6)CORI . Training, certification, and discipline remain at the
local level for EMTs and AEMTs. As of July 1, 2010, AB 2917
required every EMT candidate and certificate holder to submit
finger prints for a criminal offender record information
search including the reporting of any subsequent arrests.
Approximately 70 agencies have authority to certify EMTs.
Certifying agencies and employers investigate and verify any
information that is reported from the CORI search and must
verify in writing to EMSA that nothing in the CORI search
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precluded the individual from obtaining certification.
Regulations adopted June 17, 2010 by EMSA provide that all
certifying entities, other than a LEMSA, must advise an
applicant if anything in the CORI search indicates conduct
that would be cause for disciplinary action as specified in
statute or regulation and that the applicant must apply
directly to the medical director of the LEMSA for
certification. The June 17, 2010 regulations prescribe the
process for EMT and AEMT disciplinary action generally. They
also specify the process for an applicant who has been
directed to apply to the medical director. The regulations
list nine circumstances under which the medical director must
deny or revoke certification such as a person who is on parole
or probation for any felony, has been convicted within the
preceding five years of any theft related misdemeanor or had
been convicted of murder, attempted murder, or murder for
hire. In addition, the regulations provide for circumstances
that are within the medical Director's discretion such as
certain offenses relating to controlled substances.
7)SUPPORT . The California Professional Firefighters, sponsors
of this bill, write in support that as a symbol of a stable
community and as role models, it is imperative that personnel
meet certain criteria as individuals before they are allowed
to be employed or to volunteer in the capacity of EMS
personnel. The supporters argue that currently all emergency
medical personnel are not held to the same standard with
regard to background checks. The supporters state that EMTs
are required to submit to a background check, however existing
law does not require the same in instances where an individual
without this certificate or license pursues coursework for the
express purpose of satisfying requirements that enable him or
her to be employed or volunteer in a public safety capacity
rendering first aid in an emergency setting.
8)OPPOSITION . North Coast Emergency Medical Services, on behalf
of the counties of Del Norte, Humboldt, and Lake write in
opposition that this bill appears to require a criminal record
review of all medical responders who render first aid in an
emergency setting and are required by their public safety
agency to take the EMR course. The opposition states that new
costs associated with the criminal record review could reduce
the number of volunteers and inadvertently delay emergency
medical care to rural and remote communities where a CAL-FIRE
response is unavailable or distant and ambulance transport is
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45 minutes or more away. The opposition also argues by
targeting only the EMR category, this bill omits the majority
of 9-1-1 medical responders in rural areas of the state.
According to the opposition many of their long committed First
Responders will be forced to abandon EMR training and opt
instead for the less rigorous Public Safety training to
minimize new expenses. The opposition argues that this seems
designed to punish long existing First Responders and penalize
rural volunteers and their communities who are less able than
paid urban counterparts to cover such expenses. According to
the opposition, becoming a volunteer can already cost hundreds
of dollars per individual and thousands of dollars per agency
for training and related travel without a mechanism to recover
expenses other than often declining local contributions.
The East Bay Communities Law Center writes in opposition that
this bill creates barriers to employment and volunteerism for
people with criminal records. The opposition argues that this
bill does not provide a standard for evaluating the background
check, and does not require the applicant receive a copy of
the report so that inaccurate information can be challenged.
East Bay Communities Law Center also points out that this bill
does not identify what entity must cover the costs of the
report and argues that this would either increases costs to
applicants or on taxpayers. The opposition argues that we
should not to levy more costs on applicants for first aid
training who are volunteering for public good. This
opposition also states that recent studies suggest that
statutes requiring a background check have a profound negative
impact on the hiring prospects of people with criminal records
while studies also show that economic support provided by
employment reduces recidivism.
9)PRIOR LEGISLATION .
a) AB 2917 requires the EMSA to establish a statewide EMT
registry and develop standards, guidelines, and regulations
for certification of specified EMTs. Establishes rules for
EMT certification and discipline, and for investigation of
conduct which threatens public health and safety, as
defined
b) AB 941 (Torrico) of 2007 would have required EMSA to
maintain a central registry of EMT-I and EMT-II
certification status and EMT-P licensure status, to be used
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by LEMSAs and employers of EMTs; would have required LEMSAs
to provide certification status updates; would have
required EMS providers to verify background checks; would
have required EMSA to establish guidelines for
certification and disciplinary hearings and actions; would
have required EMS providers to investigate EMTs and
implement and report disciplinary plans to LEMSA; and,
would have revised LEMSAs' disciplinary authority.
Governor Schwarzenegger vetoed AB 941. In his veto
message, he wrote: "I am concerned this bill lacks
requirements and penalties to assure timely notice when an
investigation is initiated, does not provide sufficient
authority for local medical directors to independently
initiate investigations, and fails to establish clear
standards for background checks. In addition, I am
concerned that the bill would significantly limit public
disclosure. I therefore direct the Health and Human
Services Agency to work in a collaborative manner with
stakeholders on legislation that builds on AB 941, and
improves it to get the job done."
c) SB 583 (Ridley-Thomas) of 2007 would have required EMSA
to adopt policies and procedures for EMT-I and EMT-II
disciplinary proceedings; would have required public safety
agencies to report discipline imposed on an EMT certificate
holder to the LEMSA; would have authorized a LEMSA medical
director to temporarily suspend an EMT-I or EMT-II
certificate holder employed by a public safety agency if
discipline imposed by the public safety employer was not
sufficient; and, would have required EMSA to make the final
decision on whether to uphold the temporary suspension
order issued by the LEMSA. SB 583 was held on the Senate
Appropriations Committee Suspense File.
d) SB 254 (Ashburn) of 2007 would have required EMSA to
establish standards for EMT-Is and EMT-IIs and required
EMSA and LEMSAs to be jointly responsible for statewide
licensing and discipline of EMT-Is and EMT-IIs, pursuant
regulations adopted by EMSA, and required EMSA to develop
and implement an alcohol and drug diversion program for
EMT-I, EMT-II, and EMT-P license holders. SB 254 would
have required all applicants for EMT-I and EMT-II licensure
to have a state and federal criminal history background
check. SB 254 was set for hearing in the Senate Health
Committee, but was not heard at the request of the author.
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e) AB 1086 (Torrico) of 2007 would have required EMSA to
maintain a centralized system for monitoring EMT-I and
EMT-II certification and EMT-P licensure status to be use
by employers and LEMSAs as part of the background check
process, and would have required EMS providers to verify
completion of background checks on all EMT-Is and EMT-IIs.
AB 1086 would also have required EMSA and LEMSAs to
establish and implement other disciplinary guidelines. AB
1086 was set for hearing in the Assembly Health Committee,
but was not heard at the request of the author.
f) SB 1811 (Romero) of 2006, would have prohibited a
medical director of a LEMSA from taking action against any
EMT-I certificate issued by a public safety agency until
certain policies and procedures were approve by EMSA. SB
1811 would have authorized the medical director to
temporarily suspend an EMT-I or EMT-II certificate upon
specified determinations. SB 1811 was set to be heard in
the Senate Health Committee, but was not heard at the
request of the author.
g) AB 2554 (Ridley-Thomas) of 2006, would have revised the
disciplinary authority of LEMSAs over EMTs. Governor
Schwarzenegger vetoed AB 2554, stating that it would risk
public safety by limiting the authority of the LEMSA to
take disciplinary action against EMTs. The Governor also
encouraged stakeholders to work with the Legislature and
California Health and Human Services Agency to craft
legislation that would protect public safety, reduce
duplicative enforcement, and support more consistent
oversight of EMTs.
10)POLICY ISSUES .
a) Verification process . This bill requires that the
appointing agency verify that nothing in the CORI search
precludes the individual from performing the duties of an
EMR or is not precluded from appointment because of any
reasons listed in an existing statutory provision. The
list referred to is a list of actions to be considered as
evidence of a threat to public health and safety as a basis
for denial, suspension, or revocation of certificate or
licensure of EMTs by a medical director of a LEMSA. It is
not clear how the appointing agency is supposed to make the
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required determination. With regard to EMTs, the existing
process and grounds for denial, suspension and revocation
has been the subject of multiple pieces of legislation that
has been developed over a long process involving all the
stakeholders. In addition there are complex regulations
that further spell out the details. This bill does not
include any of the existing process by reference and
therefore provides no guidance on the process to be used.
There is no opportunity for the applicant to contest if the
agency refuses to verify. There is no equivalent of the
investigatory process that applies to other EMTs. In the
absence of guidance, the process could be arbitrary and
subject to abuse.
b) Multiple duplicative reviews . The EMR training is
intended to be provided to personnel who are likely to be
on the scene of an emergency such as school bus drivers,
peace officers, or school teachers. These professions
already require criminal background records checks, but
criminal records cannot be shared unless allowed by
statute. As a result, this bill will subject these
personnel to multiple records checks if they acquire EMR
training in order to be better prepared to respond to an
emergency.
c) Costs . The EMR status is expected to be used in rural
fire departments that rely heavily on volunteers. Will
this added expense discourage volunteers and make it
difficult to staff rural fire departments?
REGISTERED SUPPORT / OPPOSITION :
Support
California Professional Firefighters (sponsor)
California State Sheriffs' Association
Emergency Medical Services Administrator's Association of
California
Opposition
California Center for Rural Policy
Del Norte Ambulance, Inc.
East Bay Community Law Center
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North Coast Emergency Medical Services (Counties of Del Norte,
Humboldt and Lake)
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097