This chapter defines terms used throughout this subtitle. In this subtitle, the following terms have the meanings indicated. Terms Defined. “Administrative law judge” means an individual appointed under State Government Article, §9-1605, Annotated Code of Maryland. “Advanced life support provider" means an individual licensed by the EMS Board as a paramedic or CRT. Advertising. “Advertising” means information communicated by any oral, electronic, written, or graphic means including handbills, newspapers, business cards, letterhead, other business stationery, television, billboards, radio, and telephone directories. “Advertising” includes ambulance markings. “Advertising” does not include novelty items such as key chains, pens, pencils, or mugs. “Air ambulance” means any aircraft designed and constructed or modified and equipped to be used, maintained, or operated as an ambulance. Ambulance. “Ambulance” or “commercial ambulance” means any motor vehicle or aircraft designed and constructed or modified and equipped to be used, maintained, or operated for the transportation of individuals who are sick, injured, wounded, or otherwise incapacitated. “Ambulance” or “commercial ambulance” does not include a motor vehicle or aircraft designed and constructed or modified and equipped with a hydraulic lift which is used, maintained, or operated exclusively for transporting, in wheelchairs, patients who do not require the use of equipment and trained personnel found in an ambulance. “Automated external defibrillator (AED)” means a medical heart monitor and defibrillator device that: Has been cleared for market by the Food and Drug Administration; Is capable of recognizing the presence or absence of ventricular fibrillation or rapid ventricular tachycardia and determining, without intervention by an operator, whether defibrillation should be performed; and Upon determination that defibrillation should be performed, automatically charges and requests delivery of an electrical impulse to an individual's heart and requires user intervention to deliver the electrical impulse or automatically continues with the delivery of the electrical impulse. “Basic life support provider” means an individual certified by the EMS Board as an emergency medical responder or an emergency medical technician. “CAMTS” means Commission on Accreditation of Medical Transport Systems. “Cardiac rescue technician (CRT)” means an individual licensed by the EMS Board as a CRT. “CMAIS” means Commercial Maryland Ambulance Information System. “Commercial ambulance crew (crew)” means: For ground ambulances, at least two EMS clinicians, one of whom may also be the driver; or For air ambulances, at least two health care providers, at least one of whom shall be an EMS clinician and one pilot as required by CAMTS. “Commercial ambulance license” means a license issued to a commercial ambulance service by MIEMSS under this subtitle, authorizing the use of a specific commercial ambulance. Commercial Ambulance Service. “Commercial ambulance service” means an individual, firm, partnership, limited liability company, corporation, association, or organization engaged in the business of transporting, by ambulance, individuals who are sick, injured, wounded, or otherwise incapacitated. “Commercial ambulance service” does not include transporting individuals in an ambulance owned by, operated by, or under the jurisdiction of a unit of State government, a political subdivision of the State, a volunteer fire company, a volunteer ambulance company, or a volunteer rescue squad or other jurisdictional EMS operational program recognized by the EMS Board. “Commercial ambulance service license” means a license issued to a commercial ambulance service by MIEMSS under this subtitle, authorizing the operation of a commercial ambulance service. “Confidential business information” means information that: Is used in the business of a commercial ambulance service; Gives the commercial ambulance service the opportunity to obtain advantage over a competitor; Is known only to the commercial ambulance service and employees or agents of the commercial ambulance service to whom the commercial ambulance service needs to confide the information; and Is kept secure from disclosure by the commercial ambulance service. “Consumer price index (CPI)” means the Consumer Price Index, U.S. City Average (seasonally unadjusted) For All Items/All Urban Consumers (CPI-U 1982/84 = 100), published in the “Monthly Labor Review” as well as other publications of the Bureau of Labor Statistics of the United States Department of Labor. “Emergency” means any sudden or serious symptoms in a patient which might indicate a condition which: Is threatening to the patient's physical or psychological well-being; and Requires immediate medical attention to prevent possible deterioration, disability, or death of the patient. “Emergency medical responder (EMR)” means an individual certified by the EMS Board as an emergency medical responder. “Emergency Medical Services (EMS) Board” means the Board established by Education Article, §13-505, Annotated Code of Maryland. “EMS clinician” means an individual licensed or certified by the EMS Board to provide emergency medical services. “Emergency medical services (EMS) provider” means an individual licensed or certified by the EMS Board to provide emergency medical services. “Emergency medical technician (EMT)” means an individual certified by the EMS Board as an emergency medical technician. “EMRC” means the Emergency Medical Resources Center operated by MIEMSS to coordinate online medical direction. “Executive Director” means the Executive Director of the Maryland Institute for Emergency Medical Services Systems. “FAA” means the Federal Aviation Administration. “Ground ambulance” means a motor vehicle designed and constructed or equipped to be used, maintained, or operated as an ambulance. “Health care provider” means a person licensed, or otherwise certified in Maryland or authorized to practice in Maryland as a: Physician; Registered nurse; Nurse practitioner; Respiratory therapist; or Emergency medical services clinician “Helipad” means a designated area usually with a prepared surface used for take-off, landing, or parking helicopters. “Heliport” means an area of land or structure used for the landings and take-offs of helicopters and may include its buildings and facilities. “Infant” means a patient who is older than 28 days and up to 1 year old. “Jurisdictional EMS operational program (jurisdiction)” means an EMS operational program which is: Approved under COMAR 30.03.02.03; and Not licensed as a commercial ambulance service under Education Article, §13-515, Annotated Code of Maryland. “MIEMSS” means the Maryland Institute for Emergency Medical Services Systems established in Education Article, §13-503, Annotated Code of Maryland. “Neonatal referral center” means an out-of-State center operating under an agreement with MIEMSS to provide comprehensive neonatal services. “Neonatal Resuscitation Program” means the neonatal resuscitation course cosponsored by the American Heart Association and the American Academy of Pediatrics. “Neonate” or “neonatal patient” means a patient who is younger than 28 days. “Neonatologist” means a pediatrician certified by the American Board of Pediatrics in neonatology. “Paramedic” means an individual licensed by the EMS Board as a paramedic. “Perinatal referral center” means a center in Maryland designated by MIEMSS, or an out-of-State center operating under an agreement with MIEMSS, to provide comprehensive obstetrical and neonatal services. “Physician” means an individual authorized to practice medicine in Maryland. “Registered nurse” means an individual authorized to practice registered nursing in Maryland. “Specialty care paramedic” means a paramedic who has successfully completed a paramedic specialty care transport course approved by the EMS Board or equivalent as determined by MIEMSS, or holds current Critical Care Paramedic or Flight Paramedic certification through the International Board of Specialty Certification, and is credentialed by a specialty care transport service under COMAR 30.03.03.06. “Specialty care transport (SCT)” means the transport of a patient who either: Requires care or monitoring commensurate within the scope of practice of a physician or registered nurse and beyond the scope of a Specialty Care Paramedic; or Meets the following conditions: Requires ongoing care or monitoring which is within the scope of a Specialty Care Paramedic as defined in the Maryland Medical Protocols for Emergency Medical Services; and Does not currently need or is not anticipated to need intervention during transport that would be beyond the scope of a Specialty Care Paramedic under the Maryland Medical Protocols for Emergency Medical Services. “State Office of Commercial Ambulance Licensing and Regulation (SOCALR)” means the MIEMSS department responsible for implementing and enforcing the provisions of this subtitle. “SYSCOM” means the Systems Communication Center operated by MIEMSS under Education Article, §13-509, Annotated Code of Maryland, and COMAR 30.07.01. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: Regulations .01—.05 adopted as an emergency provision under COMAR 14.17.02 effective July 30, 1991 (18:17 Md. R. 1913); emergency status extended at 19:2 Md. R. 150 (January 24, 1992) and 19:14 Md. R. 1282 (July 10, 1992) Regulations .01—.10 adopted effective October 12, 1992 (19:20 Md. R. 1816) Regulation .01B amended as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); amended permanently effective July 7, 1997 (24:10 Md. R. 711) Chapter recodified from COMAR 14.22.01 to COMAR 30.09.01, August, 1997 Regulations .01—.10, Licensing Program—In General, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.02, Definitions, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02B amended effective October 15, 2004 (31:20 Md. R. 1486); January 15, 2005 (31:26 Md. R. 1866); November 1, 2010 (37:21 Md. R. 1437); December 12, 2013 (40:24 Md. R. 2017); May 3, 2021 (48:9 Md. R. 361); May 27, 2024 (51:10 Md. R. 529) This chapter describes the rights of patients transported or treated by commercial ambulance services. A commercial ambulance service shall provide each patient: Considerate and respectful care; Information from the commercial ambulance service necessary in order to give informed consent for transport or treatment, or both; The opportunity to refuse transport or treatment when the patient is apparently competent to do so; Reasonable privacy concerning a patient's transportation and care; Confidentiality of all communications and records relating to patient transportation and care except to the extent otherwise required by law; Reasonable response to a request for services once the commercial ambulance service is engaged to provide service; Service that is within reasonable limits of the scheduled pickup and delivery times; Reasonable continuity of care once the commercial ambulance service is engaged to provide service; An opportunity to examine and receive an explanation of the patient's bill; An environment in the commercial ambulance free from recognized hazards and unreasonable annoyances including but not limited to: Smoking, Loud radio, and Loud conversation by the crew; and Information that commercial ambulance services operating in Maryland are regulated by the Maryland Institute for Emergency Medical Services Systems. Education Article, §13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Regulation .06A amended as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); amended permanently effective July 7, 1997 (24:10 Md. R. 711) Chapter recodified from COMAR 14.22.02 to COMAR 30.09.02, August, 1997 Regulations .01—.06, Eligibility and Application, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.02, Patient Rights, adopted effective January 10, 2000 (26:27 Md. R. 2017) This chapter governs the requirement for licensing commercial ambulance services and commercial ambulances. There shall be a State Office of Commercial Ambulance Licensing and Regulation within MIEMSS which shall implement and enforce the provisions of this subtitle. Unless otherwise specified, all communications to the Executive Director relating to this subtitle shall be addressed to Executive Director of MIEMSS, c/o State Office of Commercial Ambulance Licensing and Regulation, 653 West Pratt Street, Baltimore, Maryland 21201-1536. A person may not operate a commercial ambulance service in Maryland unless: Issued a license under Education Article, §13-515, Annotated Code of Maryland; Exempt from this subtitle under Regulation .04 of this chapter; or Issued a written waiver from SOCALR under Regulation .05 of this chapter. The following vehicles are exempt from licensure under this subtitle: Vehicles, typically referred to as wheelchair vans, equipped with a hydraulic lift used exclusively for transporting, in wheelchairs, patients who do not require equipment or trained personnel available in an ambulance; Ambulances owned by, operated by, or under the jurisdiction of a unit of State or federal government, a political subdivision of the State, a volunteer fire company, a volunteer ambulance company, or a volunteer rescue squad; and Ambulances traveling through the State, regardless of frequency, exclusively for the purpose of interstate travel. If SOCALR believes that an ambulance operating in this State may be required to be licensed under this subtitle, SOCALR may conduct an investigation to determine whether the ambulance service or ambulance is required to be licensed. The following services are exempt from licensure under this subtitle: Air ambulance services licensed and based outside Maryland which transport patients from or within Maryland less than 26 times per year; or Ambulance services licensed and based outside Maryland which transport patients: Into Maryland; or To and from Maryland for diagnostic or therapeutic services in the same calendar day. An out-of-State ambulance service seeking an exemption from a service license shall submit a completed application on the required form to SOCALR. An exemption is not valid unless issued in writing by SOCALR for a specified period of time. A commercial ambulance service granted an exemption from this subtitle shall reapply for the exemption 30 days before expiration of the exemption. A service granted an exemption from this subtitle shall submit an annual report detailing the number of patients during the previous year who were transported: From the scene of a public safety medical emergency; and From any hospital or health care facility in Maryland. When transporting patients from the scene of a public safety medical emergency, an exempt service shall transport the patient to the closest appropriate facility according to Maryland Medical Protocol for EMS Providers. SOCALR may conduct an investigation to determine if an exemption should be revoked. A service granted on exemption shall notify SOCALR of any disciplinary action taken against the service by the licensing authority in the state in which the service is licensed. An exemption may be revoked if SOCALR finds the party to whom the exemption has been granted has: Obtained or attempted to obtain an exemption by fraud or deceit; Made material omission or misrepresentation of fact on an application for an exemption; Made a material omission or misrepresentation of fact in response to an inquiry or investigation by SOCALR; Defaced, altered, removed, or obliterated any portion of or any official entry on an exemption issued by SOCALR; Interfered with SOCALR in the performance of SOCALR's duties; Failed to reapply for an exemption; Violated any applicable federal, State, or local statute or regulation; Provided patient care which fails to meet the appropriate standard; or Been disciplined by the licensing authority in the state in which the service is licensed. The authority of a county or municipal corporation to regulate a commercial ambulance service with a base of operation located outside the county or municipal corporation that is licensed under this subtitle is preempted by Education Article, §13-515, Annotated Code of Maryland. A county or municipal corporation is not preempted from regulating a commercial ambulance service with a base of operation located within its territorial boundaries, while the commercial ambulance service is operating within those territorial boundaries, so long as local legislation does not conflict with, frustrate, or diminish the intent of Education Article, §13-515, Annotated Code of Maryland, or this subtitle. SOCALR shall: Maintain a current list of licensed commercial ambulances and licensed commercial ambulance services; and Provide this list as requested. The list shall contain the: Name of the commercial ambulance service; Commercial ambulance designations that will be used in radio communications; and Type of license issued to each licensed commercial ambulance. COMAR 30.01.04 governs responses to requests for public records of MIEMSS. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Regulation .01D amended as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); amended permanently effective July 7, 1997 (24:10 Md. R. 711) Regulation .02D adopted as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); adopted permanently effective July 7, 1997 (24:10 Md. R. 711) Chapter recodified from COMAR 14.22.03 to COMAR 30.09.03, August, 1997 Regulations .01—.04, Issuance, Transfer, and Relinquishment of License, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.07, Licensing Program—In General, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .03 amended as an emergency provision effective August 31, 2001 (28:19 Md. R. 1682); emergency status extended at 29:7 Md. R. 618; emergency status expired July 30, 2002 Regulation .05 amended as an emergency provision effective May 8, 2000 (27:11 Md. R. 1076); emergency status expired November 3, 2000 Regulation .05 amended effective October 15, 2004 (31:20 Md. R. 1486) This chapter governs the eligibility, application, and renewal procedure for commercial ambulance service licenses. To be eligible for a license, a commercial ambulance service shall: Own or operate at least one ambulance: Which is licensed; or For which a license has been applied under Regulation .04 of this chapter; Have ground ambulances mechanically inspected under Regulation .05D(4) of this chapter; Have all ambulances properly staffed and equipped; Comply with all applicable statutes and regulations governing the operation of a commercial ambulance service and commercial ambulances; Have proper insurance required by Regulation .06 of this chapter; Have reliable communications as required in COMAR 30.09.10.03 and .04; Submit the intended name of the service to SOCALR for approval; Apply for a license under Regulation .03 of this chapter; and Pay the required fees. An applicant for a commercial ambulance service license shall submit a completed application to SOCALR on the required form. A completed application shall contain: The commercial ambulance service's: Name; Principal physical business address; Billing address; Telephone number; Facsimile number; E-mail address; Principal contact individual's name for official communications from MIEMSS; Principal contact individual's name for daily operations; Federal tax identification number; and Entity type; For a corporation, limited partnership, or a limited liability company: A statement that the commercial ambulance service: Is registered under the Corporations and Associations Article, Annotated Code of Maryland, in good standing; Has filed all required annual reports; and Has paid all required filing fees to the Maryland Department of Assessments and Taxation; and The name of the resident agent on file with the Charter Division of the Maryland Department of Assessments and Taxation; The principal place of business on file with or recognized by the: Charter Division of the Maryland Department of Assessments and Taxation; or Central Registration Unit of the Comptroller of the Treasury; An agreement and representation that the commercial ambulance service: Is qualified to do business in Maryland; and Will take all necessary actions to remain qualified while licensed in Maryland; For an air ambulance service: If CAMTS accredited, a copy of the current CAMTS accreditation certificate; or If CAMTS accreditation is pending: A copy of the FAA operating certificate; and Proof of compliance with CAMTS standards; All trade names under which the commercial ambulance service and any parent or subsidiary does or has ever done business; The current Maryland Medical Assistance Program provider/vendor numbers issued by the Maryland Department of Health to the commercial ambulance service under its name or any of its trade names; The CLIA (Clinical Laboratory Improvement Amendment) identification number, if issued; The street address for each location the commercial ambulance service intends to operate including where: Ambulances are parked or stored; Records are kept; Supplies are stored; Ambulance crews are quartered; and Ambulances are dispatched; The following information about management personnel and owners: Names; Addresses; Telephone numbers; and Titles; The following information about each employee who may provide patient care: Name; Type of health care certification or license and the identity of the issuer; and Certification or license number; A listing of all commercial ambulances to be operated by the service under the service license applied for with the information required for a commercial ambulance license in Regulation .05B(2) of this chapter; A signed written statement under the penalties of perjury that: There has been no attempt for the purpose of obtaining or attempting to obtain a license, to knowingly and willfully: Falsify, conceal, or omit a material fact; Make any false, fictitious, incomplete, or fraudulent statements or representations; or Make or use any false writing, document, or entry knowing the same to contain any false, fictitious, or fraudulent statement; and The signer is authorized by the commercial ambulance service identified on the application to sign the application form to execute the sworn statement; The signatures of: If a sole proprietorship, the owner; If a partnership, all general partners; If a corporation, a duly authorized corporate official accompanied by a certified corporate resolution authorizing the execution; or If a limited liability company, an authorized individual; and Any additional information which SOCALR may consider necessary. The applicant shall submit with the application the applicable fees required in Regulation .07 of this chapter together with the documents required in this subtitle. Before accepting any license for which it applied, the commercial ambulance service shall notify SOCALR of any changes to the information previously submitted on the application which occur before the license is granted, regarding: The commercial ambulances; Commercial ambulance service personnel; or Any other material information in the application. To be eligible for a commercial ambulance license, an ambulance shall: Be owned or operated by a licensed commercial ambulance service; If a ground ambulance, be marked as follows: The name of the licensed commercial ambulance service in letters at least 4 inches high, For ambulances newly licensed or repainted after January 1, 2000, if other lettering is present naming a sponsoring or serviced facility, organization, or entity, the lettering of the licensed commercial ambulance service name prominently displayed in lettering at least the same size as the lettering in §A(2)(a) of this regulation, and A unit designation number assigned by the commercial ambulance service in letters that are at least 3 inches high; If an air ambulance, be marked with: The name of the licensed commercial ambulance service in letters that are clearly visible, and Any other markings required by the FAA; and If a ground ambulance, be mechanically inspected as required under Regulation .05D(4) of this chapter; Be properly equipped as required by COMAR 30.09.07 and 30.09.10—30.09.13; Comply with all applicable statutes and regulations governing the operation of a commercial ambulance; Be properly insured as required by Regulation .06 of this chapter; and Have proper communication equipment as required in COMAR 30.09.10.04. Additional Lettering for Ground Ambulances. If the ambulance is licensed as an ALS licensed commercial ambulance, the words “Advanced Life Support” may be displayed. If the ambulance is licensed as a neonatal licensed commercial ambulance, the words “Neonatal Transport”, “Neonatal Ambulance”, or “Neonatal Intensive Care”, or similar words implying, in the judgement of SOCALR, that the ambulance is licensed as a neonatal commercial ambulance, may be displayed. The applicant shall submit a diagram of the markings intended to be displayed on the ambulance including: Numbering; Lettering; and Symbols. The applicant shall submit an application as required under Regulation .05 of this chapter. The applicant shall pay the required fees. An applicant for a commercial ambulance license shall submit a completed application to SOCALR on the required form. A completed application shall contain: The following information about the commercial ambulance service: Name, Mailing address, Phone number, and Facsimile number; The following information about the ambulance: For ground ambulances: The unit designation number assigned to each commercial ambulance by the commercial ambulance service for operational purposes, The license plate number, The state issuing the license plates, If the license plates are temporary, the issuance and expiration dates of the temporary license plates, The vehicle identification number (VIN) issued by the chassis manufacturer, The year of manufacture of the ambulance chassis, and The color scheme, insignia, trademark, monogram, name, or other distinguishing characteristics used to designate the ambulance; For air ambulances: The unit designation number assigned to each air ambulance by the commercial ambulance service for operational purposes, The FAA registration number, and The make, model, and year of manufacture; The signatures of: If a sole proprietorship, the owner, If a partnership, all general partners, If a corporation, a duly authorized corporate official accompanied by a certified corporate resolution authorizing the execution, or If a limited liability company, an authorized individual. The applicant shall pay the required fees. The applicant shall submit with the application the following documents for each ground ambulance to be licensed: A copy of the motor vehicle registration certificate; A copy of the “Application for Approval of Emergency Vehicles” approved by the Maryland Motor Vehicle Administration; A certificate of motor vehicle liability insurance required under Regulation .06 of this chapter which lists the vehicle by the vehicle identification number (VIN) number; and A copy of: If the ambulance is 1 year old or older, the inspection certificate required by Education Article, §13-515(c)(2)(iii), Annotated Code of Maryland, together with a copy of the inspection report; or If the ambulance is less than 1 year old, the certificate of origin issued by the vehicle manufacturer which includes: Manufacturer's vehicle identification number (VIN), Manufacturer's name, General description of the body, Vehicle make, Vehicle model, and Year manufactured. The applicant shall submit with the application the following documents for each air ambulance the service intends to operate in Maryland: Proof of adequate insurance; and A copy of the FAA air worthiness certification. Before the license is granted, the commercial ambulance service shall notify SOCALR of any changes to the information in the application which occur after the application is submitted. A commercial ambulance service or a commercial ambulance may not be licensed or operated in Maryland unless the commercial ambulance service maintains continuous insurance, issued by an insurer authorized by the Maryland Insurance Commissioner to write these policies in Maryland, of the following types and amounts: Commercial general liability insurance coverage of not less than $1 million; For ground ambulances, commercial motor vehicle liability insurance coverage of not less than the minimum required under Transportation Article, §17-103, Annotated Code of Maryland; and Workers' compensation insurance in the amount required by law. The general liability insurance coverage required by §A(1) of this regulation shall provide for payment of damages as a result of: Bodily injury to, or death of, individuals in accidents resulting from any cause for which the commercial ambulance service is liable; and Property damage to or loss of the property of another, including personal property, resulting from any cause for which the commercial ambulance service is liable. The financial responsibility requirements for commercial motor vehicle liability coverage shall conform to all applicable laws including: Transportation Article, Title 17, Annotated Code of Maryland; Transportation Article, Title 18, Annotated Code of Maryland; COMAR 11.18; and Insurance Article, Title 19, Subtitle 5, Annotated Code of Maryland. The financial responsibility requirements for workers' compensation insurance shall comply with Labor and Employment Article, Title 9, Annotated Code of Maryland. A commercial ambulance service shall provide SOCALR, as a condition of licensure or continued licensure, a certificate of insurance that: Verifies that the insurance required under this regulation is in effect at the time the application is submitted; and Lists the State Office of Commercial Ambulance Licensing and Regulation, 653 West Pratt Street, Room 313, Baltimore, Maryland 21201-1536, as an additional party entitled to notification 10 days before any of the following relating to insurance required by this chapter occurs: Nonrenewal, Cancellation, or Substantive change in the coverage or level of insurance. A certificate of insurance for motor vehicle insurance required under §E of this regulation shall identify all vehicles covered by the manufacturer's vehicle identification number (VIN). In addition to the notification requirements required by Insurance Article, §27-605, Annotated Code of Maryland, and this subtitle, a commercial ambulance service shall furnish to SOCALR, within 7 calendar days of receipt, copies of notification from an insurer of any of the following relating to insurance required by this chapter: Nonrenewal; Cancellation; or Substantive change in the coverage or level of insurance. If the insurance coverage provided by an insurance company or a self-insurance fund is not adequate for the purposes required, MIEMSS may not issue a license. Commercial Ambulance License Fees. Ground ambulances. Annual commercial ambulance ALS or BLS license fee as of July 1,1999 — $780 Semiannual commercial ambulance ALS or BLS license fee as of July 1, 1999 — $415 Specialty Care Transport Service License. Annual commercial specialty care service license fee as of December 31, 2004 — $500. Semiannual commercial specialty care service license fee as of December 31, 2004 — $265. Annual neonatal commercial ambulance license fee as of July 1, 1999 — $940 Semiannual neonatal commercial ambulance license fee as of July 1, 1999 — $500 Commercial Air Ambulance Service License. Annual commercial air ambulance service license fee as of July 1, 2002 — $845. Semiannual commercial air ambulance service license fee as of July 1, 2002 — $450. Specialty Care Transport Service License. Annual commercial specialty care service license fee as of December 31, 2004 — $500. Semiannual commercial specialty care service license fee as of December 31, 2004 — $265. Miscellaneous Service Fees. Ambulance license transfer — $50 Change in level of ambulance license — $50 Preliminary determination to prospective buyer — $100 Replacement of commercial ambulance vehicle license — $5 Replacement of commercial ambulance service license — $5 Replacement of ambulance licensing decal — $10 Service license application packet — $20. Initial service license application review — $100. The licensing fee for adding a commercial ambulance vehicle during the fiscal year is: One half of the semiannual fee rounded to the nearest $5 increment if the vehicle is added after April 1 and before June 30 of the current fiscal year; Equal to the semiannual fee if the vehicle is added after January 1 and before March 31 of the current fiscal year; Equal to the semiannual fee rounded to the nearest $5 increment if the vehicle is added after October 1 and before December 31 of the current fiscal year; or Equal to the annual fee if the vehicle is added after July 1 and before September 30 of the current fiscal year. SOCALR shall make noninflationary adjustments to the fees listed in §§A and B of this regulation by means of the regulatory promulgation process which affords interested parties the opportunity to make both oral and written comments to SOCALR before the adoption of a new fee schedule. The fees established in §§A and B of this regulation may be adjusted by SOCALR, from time to time, notwithstanding the inflationary adjustment in §E of this regulation, in order to provide funds sufficient to cover the actual direct and indirect costs of maintaining the licensing program in accordance with Education Article, §13-515, Annotated Code of Maryland, and this subtitle. SOCALR may make inflationary adjustments to the fees listed in §§A and B of this regulation before the beginning of each fiscal year by applying the percent change in the consumer price index for the most recent complete calendar year to the annual licensing fee for the fiscal year ending rounded to the nearest $5 increment. This inflationary adjustment may be made by SOCALR without any additional consultation or amendment to the regulations. If the consumer price index ceases to be published, a comparable statistic on the purchasing power of the consumer dollar shall be adopted. If the base year (1982/84 = 100) or other base year used in computing the consumer price index is changed, the figures used in making the computation below shall be changed accordingly. The following formula shall be used in determining the annual inflationary adjustment to the fees: SOCALR may set semiannual licensing fees that are adjusted to cover the additional costs incurred for semiannual rather than annual processing of licenses and decals. The semiannual licensing fee shall be one half of the annual licensing fee plus 6 percent of the halved annual fee, the sum of which is rounded to the nearest $5 increment. Additional Fees. SOCALR may set fees to recoup, on a cost basis, the cost of services and materials that are not covered by the licensing fees, provided to commercial ambulance services and other interested parties. These materials and services may include: MAIS run reports; Additional narratives; Instruction booklets; Triage tags; Protocols; Certification or license patches; Reproduction of documents; Production of statistical reports; Copies of statutes and regulations; and Bank service charges for checks returned for insufficient funds. The price adjustments in §G(1) of this regulation may be made by SOCALR as necessary without any additional consultation or amendments to the regulations, if these fees are published in the fee schedule distributed in accordance with §H of this regulation. When the fee schedule is adjusted, SOCALR shall provide a copy of the new fee schedule to all commercial ambulance services that: Are licensed by SOCALR at the time of issuance of any new or revised fee schedule; or Apply for a license after the issuance of each new or revised fee schedule. All applicable fees listed in the fee schedule currently in effect shall be submitted to SOCALR with each application. A license fee may not be refunded, in whole or in part, to any commercial ambulance service whose service or vehicle license is suspended or revoked. SOCALR may waive any equipment requirements under COMAR 30.09 for any commercial ambulance service which is licensed by Maryland or applying for a license, which demonstrates to the satisfaction of SOCALR that the equipment offered by the commercial ambulance service is equivalent to or superior to the equipment required by this subtitle. Waiver of Personnel Requirements. SOCALR may waive any personnel requirements under COMAR 30.09 for any commercial ambulance service which is licensed by Maryland or applying for a license, which demonstrates to the satisfaction of SOCALR that the personnel offered by the commercial ambulance service is equivalent to or superior to the personnel required by this subtitle, except the requirement for a licensed or certified driver for an ambulance, which may only be waived under §B(2) of this regulation. SOCALR may waive the personnel requirements under COMAR 30.09 for a licensed or certified driver for any commercial ambulance service which is licensed by Maryland or applying for a license. The initial waiver shall be for 1 year, subject to renewal. A commercial ambulance service seeking or maintaining a waiver of the requirement for a licensed or certified driver for an ambulance under COMAR 30.09 shall meet the following requirements: Submit to SOCALR with the application and on a monthly basis: The current number of unit hours staffed over a consecutive 7-day period during the most recent 30 days; and The name and address of each non-EMS individual designated by the commercial service to drive an ambulance; Ensure that each non-EMS individual designated to drive an ambulance possesses a current and valid For-Hire Driver's license issued by the Public Service Commission prior to use of a non-EMS driver on an ambulance; Provide to SOCALR a photocopy of a current and valid For-Hire Driver's license issued by the Public Service Commission for each non-EMS individual designated to drive an ambulance prior to use of a non-EMS drive on an ambulance; Ensure that each non-EMS individual designated to drive an ambulance obtains an ePINS number prior to use of a non-EMS driver on an ambulance; Provide the following training to each non-EMS individual it designates to drive an ambulance prior to use of a non-EMS driver on an ambulance: COMAR 30.09.02.02 — Patient Rights; COMAR 30.09.07.03 — Operational Requirements; Bloodborne Pathogens (29 CFR 1910.1030 to include Personal Protective Equipment and Body Substance Isolation precautions); Lifting, moving, or positioning patients, to include stretcher and stair chair operations; CPR certification training, including the use of an AED; and Driver's training program to include safe road operations, ambulance backing, and city driving; Provide SOCALR with a copy of the training programs required for the non-EMS driver prior to use of a non-EMS driver on an ambulance; Ensure that any ALS licensed ground ambulance that is staffed with a non-EMS driver is also staffed with at least two individuals who meet the following requirements: A CRT or higher who is responsible for the patient as described in COMAR 30.09.07.02A(4)(b); and An EMT or higher; and Ensure that any non-EMS individual designated to drive an ambulance: Is not subject to a current suspension or revocation of EMS licensure or certification; and Has not been determined by SOCALR to be a threat to the health and safety of patients or the public. A commercial ambulance service seeking a waiver under this regulation shall apply in writing to SOCALR. A waiver is not valid unless issued in writing by SOCALR for a specific period of time. A commercial ambulance service granted a waiver under this subtitle shall reapply for the waiver 30 days before expiration of the waiver. A waiver may be summarily suspended if SOCALR finds the party to whom the waiver has been granted has: Obtained or attempted to obtain a waiver by fraud or deceit; Made a material omission or misrepresentation of fact on an application for a waiver; Made a material omission or misrepresentation of fact in response to an inquiry or investigation by SOCALR; Defaced, altered, removed, or obliterated any portion of or any official entry on a waiver issued by SOCALR; Interfered with SOCALR in the performance of SOCALR's duties; Failed to reapply for a waiver; Violated any applicable federal, State, or local statute or regulation; Failed to comply with the terms of the waiver; or Continued to use a non-EMS driver that SOCALR has determined, in conjunction with the MIEMSS Office of Integrity, to be a threat to the health and safety of patients or the public. Failure to comply with the terms of a waiver granted under this regulation may be grounds for further action under COMAR 30.09.09.02. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.04 to COMAR 30.09.04, August, 1997 Regulations .01—.02, Advertisement and Licensure Disclosure, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.07, Eligibility, Application, and License Renewal, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02 amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .03B amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .04A, B amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .05 amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .06A amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .07 amended effective January 15, 2005 (31:26 Md. R. 1866) Regulation .07A amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .08 adopted effective May 14, 2001 (28:9 Md. R. 892) Regulation .08 amended effective July 7, 2025 (52:13 Md. R. 657) Regulation .08B, F amended as an emergency provision effective August 26, 2021 (48:20 Md. R. 850); amended permanently effective January 13, 2022 (49:1 Md. R. 16) Regulation .08G adopted as an emergency provision effective August 26, 2021 (48:20 Md. R. 850); amended permanently effective January 13, 2022 (49:1 Md. R. 16) This chapter governs the issuance, transfer, and relinquishment of licenses for commercial ambulances. SOCALR shall issue a license to an applicant that: Files the required application; Files the required supporting documentation; Pays the required fees; and Meets the other requirements of this subtitle for licensure. Before issuing a license, SOCALR may verify information relating to an application by: Inspecting supporting documents; Inspecting a commercial ambulance service; Inspecting commercial ambulances; and Requiring a conference with the applicant. SOCALR may not issue a license to an applicant whose name is, in the judgement of SOCALR, confusingly similar to another person doing business in Maryland, or who otherwise has the right to use the name in Maryland. A licensed commercial ambulance service shall produce its license upon demand of any person. Unless revoked or surrendered, a commercial ambulance service license or ambulance license shall expire at midnight on the date indicated on the license. A revoked or surrendered commercial ambulance service license or ambulance license shall expire immediately upon notification. SOCALR shall affix a licensing decal to a commercial ground ambulance when it is licensed. The decal shall be displayed at all times on the outside of the back surface of the ambulance in a manner clearly visible to the public. A licensing decal is not proof of a valid license. Licenses and licensing decals issued by MIEMSS at all times remain the property of MIEMSS. A licensee shall apply for a new license at least 14 calendar days before the current license expires. To renew a license, the licensee shall apply to SOCALR under COMAR 30.09.03—30.09.05. If a commercial ambulance license is not renewed, the ambulance owner shall contact SOCALR to have the ambulance licensing decals removed from its ambulances under Regulation .09 of this chapter. A commercial ambulance service license or ambulance license issued by MIEMSS may not be transferred or assigned without the prior written approval of MIEMSS. The owner of a Maryland licensed commercial ambulance service wishing to merge with or acquire the assets or stock of another Maryland licensed commercial ambulance service may submit a letter of intent for the purpose of transferring the service and ambulance licenses to the successor service. Information submitted to SOCALR relating to the possible transfer of vehicle licenses in a potential merger or acquisition are confidential until a license is issued to the successor, except as otherwise required by law. If a successor service continues to do business in the name of and at the principal address of a merged or acquired service as it appears on the service license issued to the merged or acquired service and vehicles are not added at the time of merger or acquisition, the ground ambulance transfer fee is not imposed on the successor service in connection with the merger or acquisition. If a successor service changes the name or principal address of a merged or acquired service or any other information appearing on a ground ambulance license, a transfer fee shall be paid for each ground ambulance which is relicensed. The licensing fee required by COMAR 30.09.04.07 shall be paid for any additional ground ambulances licensed at the time of a merger or acquisition. A prospective purchaser of the stock or assets of a commercial ambulance service, with the written permission of current ownership, may apply to SOCALR for a preliminary determination of the eligibility of the prospective purchaser for a commercial ambulance service license based on the eligibility criteria in COMAR 30.09.04. There is a fee for preliminary review of a license application submitted by a prospective buyer. Any information submitted to SOCALR relating to a potential acquisition of a commercial ambulance service is confidential until a license is issued to the successor, except as otherwise required by law. If the purchaser changes the name or principal address of the acquired service or any information on a ground ambulance license, a vehicle license transfer fee shall apply for each vehicle to be relicensed. The licensing fee required in COMAR 30.09.04.07 shall be paid for any additional ground ambulance licensed at the time of purchase. A licensed commercial ambulance service may apply to SOCALR to transfer a commercial ground ambulance license from one of its ambulances to another if the transfer does not result in a net increase in the number of ground ambulances operated by the licensee. Any net increase in the number of ground ambulances operated by the licensee is: Treated as an addition to the fleet rather than a transfer; and Subject to payment of the entire annual, semiannual, or quarterly ambulance licensing fee. A commercial ambulance service shall contact SOCALR to have the ambulance licensing decals removed from its ambulances: Before it is sold; or Within 14 calendar days of cessation of operations. If a licensed commercial ambulance service is sold or ceases to operate, the service shall return the ambulance service license and all ground ambulance licenses to SOCALR within 14 calendar days of the sale or cessation of operation. A commercial ambulance service shall contact SOCALR to have the ambulance's licensing decals removed: Before the ambulance is sold; or Within 14 calendar days of the date the ambulance is permanently placed out of service. A commercial ambulance service shall return to SOCALR a commercial ambulance license: Before selling the ambulance; or Within 14 calendar days of permanently placing the ambulance out of service. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.05 to COMAR 30.09.05, August, 1997 Regulations .01—.07, Operational Requirements, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.09, Issuance, Transfer, and Relinquishment of Licenses, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02G amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .05C—E amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .06D, E amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .07A, B amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .08B amended effective October 15, 2004 (31:20 Md. R. 1486) This chapter governs advertising of commercial ambulance services and required disclosure of licensing information. Commercial ambulance service advertisements shall contain: The legal name or trade name of the commercial ambulance service stated on the license issued by MIEMSS; and The designation "Md.Comm.Amb.Lic.#" followed by the ambulance service license number issued by MIEMSS. The license designation number requirement under §A(2) of this regulation does not apply to the ambulance. A commercial ambulance service that advertises 24-hour service shall: Operate 24 hours a day every day of the year; Provide uninterrupted service; and Have at least one employee answering the commercial ambulance service telephone. All commercial ambulance service advertisements shall comply with applicable laws, including the Consumer Protection Act, Commercial Law Article, Title 13, Annotated Code of Maryland, which prohibits unfair or deceptive trade practices and false, misleading, or deceptive advertising. Each commercial ambulance service proposal or contract for services shall contain the: Designation "Md.Comm.Amb.Lic.#" followed by the ambulance service license number issued by MIEMSS; and Following notice: Each commercial ambulance service invoice for services shall contain the designation "Md.Comm.Amb.Lic.#" followed by the ambulance service license number issued by SOCALR. Education Article, §13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.06 to COMAR 30.09.06, August, 1997 Regulations .01—.03, Personnel, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.03, Advertisement and Licensure Disclosure, adopted effective January 10, 2000 (26:27 Md. R. 2017) This chapter governs the operational requirements for commercial ambulance services and commercial ambulances. Staffing. A commercial ambulance service shall: Staff each ambulance with a minimum of two EMS providers; Require that EMS providers: Have a valid identification card issued by MIEMSS showing the provider is licensed or certified by the EMS Board in their possession while on duty; and Upon request of SOCALR, provide their certification or license for inspection; Assure that each BLS licensed ground ambulance is staffed with: A driver who is certified as emergency medical responder or higher and possesses and, while on duty, carries a valid motor vehicle license; and An individual in addition to the driver who is an emergency medical technician or higher, who is responsible for the patient until the patient is: Discharged in accordance with written physician orders; or Delivered to a medical facility, nursing home, residence, or other home care system appropriate for the patient's condition; Assure that each ALS licensed ground ambulance is staffed with: A driver who is certified as an emergency medical responder or higher and possesses and, while on duty, carries a valid motor vehicle license; and An individual in addition to the driver who is a licensed CRT or higher, who is responsible for the patient until the patient is: Discharged in accordance with written physician orders; or Delivered to a medical facility, nursing home, residence, or other home care system appropriate for the patient's condition; Assure that each air ambulance is staffed with a commercial ambulance crew and as required by CAMTS; Require that each nurse who is a regular crew member be familiar with the Maryland Protocols for EMS Providers; Require all employees to clearly display personal identification in readable text which includes the: Employee's last name; and Certification or license held by the individual; Require EMS providers to wear a certification or license insignia which is clearly displayed on the EMS providers' outermost garments; Require that employees display only valid certification or license identification or insignias; and Assure that EMS providers do not wear or display identification suggesting affiliation with any other service, organization, department, company, or agency. Premises. A commercial ambulance service shall: Display its commercial ambulance service license, or a copy of it, at all locations of operation in a manner clearly visible to the public, at all times; Make readily available at all times for review by employees at the operating base and all satellite bases a current copy of: COMAR 30.01; COMAR 30.02; COMAR 30.03; COMAR 30.04; COMAR 30.09; and The documents incorporated by reference in this title; Maintain the premises identified on the application in a clean and orderly manner; and Upon request from SOCALR, allow the inspection of the areas in which are located the commercial ambulance service's: Primary place of business; Satellite offices; and Records. Infection Control Standards. An ambulance service shall: Use freshly laundered linen or disposable sheets and pillowcases or their equivalent for each patient; Show evidence of sanitary laundering arrangements, acceptable to SOCALR, for reusable linen; Store medical supplies in a clean and sanitary manner; Clean all equipment used after each patient; including: Ambulance stretcher; and Stretcher mattress; Clean the patient compartment surfaces in the ambulance at least daily, and use a disinfectant in accordance with 29 CFR §1910.1030: When surfaces become obviously contaminated; After any spill of blood or other potentially infectious material; and Routinely throughout the work shift if contamination might have occurred; Provide adequate hand-washing facilities with: Hot and cold running water; Antiseptic soap; and A sanitary method for hand drying; Require that each crew member wash their hands with an antiseptic agent before and after each patient contact; Dispose of equipment or supplies that are not reusable after use; Disinfect equipment or supplies intended to be clean but not sterile after each use or when they become soiled; and Sterilize equipment or supplies after each use or when sterility has been compromised. A commercial ambulance service may not transport a corpse unless: There is a compelling public interest for moving the body or body parts; Transport is not readily available by a funeral home; and An authorized representative of the Office of the Chief Medical Examiner requests transport. After the transport of a body in accordance with §C(2) of this regulation, a commercial ambulance service shall assure that the ambulance patient compartment is disinfected. Training and Continuing Education Requirements. A commercial ambulance service shall: Provide an orientation to all new employees that includes a review of: COMAR 30.02; COMAR 30.09; and The documents incorporated by reference in Title 30; Before assigning duties and at least annually thereafter provide training at no cost to all employees which includes: Blood-borne pathogens in accordance with 29 CFR §1910.1030; Hazard Communication Plan in accordance with 29 CFR §1910.1200; FDA Medical Device Reporting in accordance with 21 CFR 803 et al.; and Other training required by the Maryland Occupational Safety and Health regulations; Provide for adequate training and continuing education opportunities to fulfill the minimum recertification or license renewal requirements for EMS providers; and Absorb the cost for providing training that will meet the recertification or relicensure requirements of EMS providers who worked for the commercial service an average of 20 hours per week for the previous 12 months. Medical Direction Requirements. A commercial ambulance service shall: Retain one or more participating physicians who agree to: Assume physician responsibilities for the commercial ambulance service and its EMS providers; and Comply with all applicable sections of COMAR 30.03; and Provide an EMS skills review for the commercial ambulance service's EMS providers which meets their recertification and relicensing requirements. Compliance with Statutes and Regulations. A commercial ambulance service shall: Comply with all applicable laws, including: COMAR 30.02; COMAR 30.03; COMAR 30.09; and The requirements contained in Maryland Medical Protocols for Emergency Medical Providers; Maintain uninterrupted and continuous insurance coverage as required in COMAR 30.09.04.06; Monitor the care provided by its EMS providers and ambulance drivers on an ongoing basis; Within 72 hours of occurrence, report any violations of: COMAR 30.02; COMAR 30.09; or The documents incorporated by reference in this title; Comply with all local, State, and federal laws and regulations including: Transportation Article, §11-101—27-109, Annotated Code of Maryland (relating to motor vehicle and emergency vehicle operations); COMAR 11.14 (relating to motor vehicle safety requirements); Maryland Department of Health regulations under COMAR Title 10; Maryland Occupational Safety and Health regulations under COMAR 09.12; 29 CFR §1910.1030 (relating to blood-borne pathogens); 29 CFR §1910.1200 (Hazard Communications/Employee Right to Know); and 21 CFR 803 et al. (FDA Medical Device Reporting Requirements). A commercial ambulance service shall: Only dispatch an ambulance if: The ambulance and crew can: Arrive at the scene within a reasonable response time; Provide appropriate transportation; and Provide appropriate medical care; The ambulance has available all of the following in adequate amounts to meet the needs of the patient being transported: Adequate supplies; Adequate equipment; All equipment assembled and ready for use, except items that are sterile; All portable oxygen cylinders which have a total of 210 liters at 1500 psi or more, excluding any cylinder with less than 500 psi; A cylinder attached to the portable oxygen administration device with more than 500 psi, and, if present, an onboard cylinder which has more than 300 psi; Sufficient oxygen available, after deducting for a safe residual pressure of 200 psi per cylinder, to meet the needs of the patient being transported based on the expected flow rate and the required duration of transport given the following formula and cylinder constants: Oxygen cylinders located in the patient compartment secured by a crash stable bracket that meets: For ground ambulances, the test requirements in Ambulance Manufacturers Division Oxygen Tank Retention Standard 003; or For air ambulances, FAA requirements; Oxygen cylinders located in a compartment other than the patient compartment secured in a bracket appropriate for the cylinder that has: A positive locking latch, and Both latch and hinges bolted to the door frame structure; Communication equipment required in COMAR 30.09.10.04C which: Is reliable, and Can properly communicate with the ambulance services dispatch center from the time of dispatch until time call is completed; Communication equipment required in COMAR 30.09.10.04D which: Is reliable, Can properly communicate with online medical control in Maryland, and Meets the specifications set forth by the MIEMSS Emergency Medical Services Communications; A reliable means of communication from the point of dispatch until the patient reaches the final destination; The ambulance crew is adequately trained to safely: Operate an ambulance; and Use the equipment and supplies onboard; Place medical supplies out of service as they expire and properly discard medical supplies which are expired; Place malfunctioning medical equipment out of service until the equipment has been repaired or replaced; Have an adequate number of AEDs to provide one AED on every: BLS licensed ambulance in service; and ALS licensed ambulance in service operating as a BLS ambulance; For ground ambulances, have each ambulance inspected every 12 months by an inspection station licensed under Transportation Article, §23-103, Annotated Code of Maryland; For ground ambulances, designate and maintain ambulances as emergency vehicles by equipping them with necessary: Lights; Sirens; and Special markings; Under Transportation Article, §11-118, Annotated Code of Maryland, equip and operate only ambulances as emergency vehicles; Always operate each ambulance with due regard for the public; Only use emergency warning lights and audible warning devices when: En route to an emergency as a result of a call for assistance made directly to the commercial ambulance service; or Transporting a priority 1 patient; Maintain in proper working order and good physical condition and, where applicable, meet all manufacturers recommendations for all: Equipment; and Ambulances; Display the ambulance license, or a copy, in the patient compartment in a manner clearly visible to the patient; Prohibit smoking or the carrying of lighted tobacco products on ambulances; For ground ambulances, prohibit an ambulance to be driven, and may not allow any passengers or patients on board, until necessary repairs are completed and an inspection conducted if any of the following occur: An occupant complains of symptoms associated with or has been affected by carbon monoxide as a result of riding in the ambulance; Carbon monoxide levels at or above 9 parts per million are detected in the interior of the ambulance; or A mechanical condition is discovered that is reasonably likely to produce a carbon monoxide hazard to the occupants; Assure occupants are safely transported in ambulances by: Requiring all occupants to wear safety restraints, except as necessary to attend to a patient; Requiring all patients to be secured to stretchers in accordance with the stretcher manufacturer's recommendation, except as may be necessary for treatment; For ground ambulances: Operating an ambulance only when the ambulance is equipped with devices that comply with federal motor vehicle safety standards (49 CFR Part 571) for: Restraints; Anchors; and Mechanisms; and Transport children younger than 4 years old, who are passengers and not patients, only in the front passenger compartment when: The child is secured in a child passenger restraint system which meets State and federal motor vehicle safety standards; and The vehicle is not equipped with a passenger air bag; Stow or adequately fasten all medical devices, supplies, or equipment to the satisfaction of SOCALR to prevent items from becoming projectiles that might cause injury in an abrupt stop or crash; Assure that compartments used to carry heavier items, first aid kits, portable oxygen cylinders, suction units, intravenous pumps, ventilators, and monitors have positively locking latches: With both latch and hinge bolted to the door and frame structure; and That are designed to remain closed in an abrupt stop or crash, including rollovers; and Carry intravenous fluids, saline, sterile water, or other fluids only in bags or plastic bottles unless: A specific required fluid is only available in a glass container; and Protective measures are employed to protect occupants from broken glass in the event of breakage. Unless requested to do so by a jurisdiction's communications center or unless standing by under contract with the organizer of an event, a commercial ambulance service may not respond to an emergency incident which: Occurs on a public street, public alley, public way, or public place of the State, where emergency units of a jurisdictional EMS operational program have the responsibility for rendering emergency service; Involves mass casualties or requires care of more than one individual as a result of the same incident; Involves hazardous, incendiary, or explosive materials; Involves a trapped person who requires extrication or forcible entry; Involves an uncontained fire; Involves imminent danger to parties or property other than the patient for which the commercial ambulance service is being called upon to render service; or Requires resources that the commercial ambulance service does not have. If a commercial ambulance service and jurisdiction units respond to a call for assistance for the same patient or incident, the commercial ambulance service shall defer to the jurisdictional EMS operational unit unless the patient, or the patient's legal guardian, when competent to do so, expressly requests care or transport, or both, from the commercial ambulance service instead of the jurisdictional EMS operational unit. If an uncommitted commercial ambulance crew chooses to render assistance or medical care at an emergency, such as those described under §A of this regulation and can do so without the crew members themselves becoming victims, and no jurisdictional EMS providers are immediately available, the following procedure applies: The commercial ambulance service shall immediately contact the jurisdiction's communications center by the most expeditious means available to the ambulance service, and advise the communications center of the: Nature and location of the emergency, Identity of the commercial ambulance service and ambulance, and Level of care capability of the ambulance; If a jurisdiction dispatches units to the scene, the commercial ambulance crew shall care for the patient or patients within the scope of the ambulance crew's health care certification or license for the ambulance they are operating until representatives of the jurisdiction's emergency medical services arrive; A jurisdiction may request the commercial ambulance service to effect the transport; and A commercial ambulance service electing to comply with a jurisdiction's request may only charge the patient for services or transport rendered if the jurisdiction would have charged the patient. A commercial ambulance service that requests a jurisdiction to assist them with manpower or equipment shall: If requested by jurisdictional authorities immediately defer patient care and scene control to jurisdictional authorities on scene; and At the discretion of the local jurisdiction authorities on the scene, complete the call after the assistance requested has been provided. Voluntary Service during Disasters. A jurisdictional EMS operational program may directly, or through MIEMSS, request assistance from commercial ambulance services licensed under this subtitle. A commercial ambulance service may, but is not required to, provide assistance in response to a request from a jurisdictional EMS operational program. A commercial ambulance service electing to respond to an incident in response to a request for assistance shall: Respond to a staging site established by the jurisdictional EMS operational program; and Operate under the command and control of the jurisdictional EMS operational program. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.07 to COMAR 30.09.07, August, 1997 Regulations .01—.10, Minimum Equipment, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.04, Operational Requirements, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02A amended effective October 15, 2004 (31:20 Md. R. 1486); December 19, 2005 (32:25 Md. R. 1948); December 12, 2013 (40:24 Md. R. 2017) Regulation .02A amended as an emergency provision effective January 1, 2020 (47:1 Md. R. 11); amended permanently effective June 15, 2020 (47:12 Md. R. 598) Regulation .03 amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .04 amended effective October 15, 2004 (31:20 Md. R. 1486) This chapter governs the record keeping and submission requirements for commercial ambulance services and commercial ambulances. A commercial ambulance service shall: Maintain records in any permanent form including: Paper, or Magnetic media; Organize all records in such a manner as to allow the commercial ambulance service to locate, within a reasonable time, a record, given: A patient's name, Date and time of a call, and Pick up or discharge location; and Retain all records for not less than 5 years and in accordance with: Local law, State law, and Federal law. A commercial ambulance service shall maintain complete and accurate records regarding the care and transportation of each patient that the commercial ambulance service: Responds to transport; Agrees to transport; or Transports to, from, or within the State. A record for each patient referred to in §A of this regulation shall contain the following information: Patient's name; Patient's residence address; Date and time of scheduled pickup; Location of pick up; Date of service; Time dispatched; Commercial ambulance number; Time en route to pick up location; Time arrived at pick up location; Time en route to destination; Patient's destination; Time arrived at destination; Referring physician; Receiving physician, if available; and Pertinent remarks. A commercial ambulance service shall use the standard Maryland Ambulance Information System runsheet and additional narrative supplied at cost by SOCALR. A commercial ambulance service shall maintain: A complete and current personnel list which includes: EMS providers; Ambulance drivers; Registered nurses; and Any other medical personnel employed; Personnel lists which include each employee's: Full name; and Health care certification or license: Number, Level, Date of issuance, and Date of expiration; Accurate and completed employee training records for: New employee orientation; Continuing education; and All training required for compliance with this subtitle; Training records that document: Date training provided; Course outline; Employee attendance; Instructor name; and Instructor's qualifications; and Accurate records of employee: Communicable disease exposure histories; Immunization records; and Yearly TB screening. A commercial ambulance service shall: Complete dated inventory sheets daily to ensure each ambulance is: Clean, Has adequate supplies, and Is in compliance with COMAR 11.14; and Maintain a written policy detailing the procedures to be followed if a mechanical failure occurs with the ambulance when responding to or transporting a patient. A commercial ambulance service shall: Upon reasonable request from SOCALR, submit within a reasonable time: Reports; Surveys; Complaint investigation findings; Patient care records; Personnel records; Training records; and Vehicle records; Notify SOCALR orally within 72 hours, and in writing within 5 calendar days, of all: New names registered with the Maryland Department of Assessments and Taxation for the purpose of doing business; Additions, or deletions, to the physical locations of operation; Changes in: Medical direction, ALS coordinator, Information included on an application, and Operation of the ambulance service; Reports submitted to the deputy State health officer in accordance with COMAR 10.06.01; Reports submitted in accordance with COMAR 30.03.04; Violations of this subtitle by: A commercial ambulance service employee, or Anyone acting as an agent for a commercial ambulance service; Events involving the commercial ambulance service which results in: Bodily injury, or Death; Submit every proposed change to ambulance markings for review and approval before making any changes to ambulance markings, including but not limited to: Numbering; Lettering; or Symbols; Submit by the 15th of each month for the preceding month a complete and accurate MAIS report for each patient that the commercial ambulance service: Responds to transport; Agrees to transport; or Transports to, from, or within the State; Submit a current personnel list quarterly, before the 15th of January, April, July, and October; and Submit by the 15th of each month for the preceding month a summary report listing the number of calls for the month that were: BLS; ALS; Neonatal; SCT; Accompanied by a physician, nurse, or other health care provider; Referred to 911; or BLS calls in which the AED was used. Education Article, §13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.08 to COMAR 30.09.08, August, 1997 Regulations .01—.02, Record Keeping and Reporting, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.06, Record Keeping and Submission Requirements, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .06F amended effective January 15, 2005 (31:26 Md. R. 1866) This chapter governs the enforcement of commercial ambulance statutes and regulations. If a licensee or applicant violates Education Article, §13-515, Annotated Code of Maryland, or this subtitle, SOCALR may: Deny the applicant's application; or Suspend or revoke the licensee's license. If a person granted a waiver of the requirements of Education Article, §13-515, Annotated Code of Maryland, by MIEMSS violates the provisions of this subtitle, MIEMSS may rescind the waiver. The following conduct is prohibited: Obtaining, attempting to obtain, or maintaining a waiver by fraud or deceit; Making a material omission or misrepresentation of fact on an application for a license or a waiver; Making a material omission or misrepresentation of fact in response to an inquiry or investigation by SOCALR for the purposes of determining compliance or investigating a complaint; Defacing, altering, removing, or obliterating any portion of or any official entry on a license, licensing decal, or waiver issued by SOCALR; Interfering with SOCALR in the performance of its duties; Failing to pay applicable licensing fees; Failing to pay the cost of services and materials provided to the commercial ambulance service by MIEMSS; Failing to comply with the requirements of a noncompliance notice or remedial action; Receiving multiple noncompliance notices which in SOCALR's judgment are of sufficient quantity, severity, or frequency to require more severe action to ensure the health, safety, and welfare of those persons utilizing the services of a particular commercial ambulance service; Violating Education Article, §13-515, Annotated Code of Maryland; Violating this subtitle; or Under the laws of the United States or of any state, conviction of any owner, Maryland based principal, or individual with substantial control over the finances, operations, or both of the service, for a felony or a misdemeanor that is directly related to the fitness and qualification of the applicant or licensee to provide commercial ambulance services. A commercial ambulance service licensed by SOCALR shall: Have a written procedure for responding to complaints about service; Provide a copy of its complaint procedure to any person upon request; and Notify each complainant of the right to file a complaint with SOCALR if not satisfied with the response of the commercial ambulance service. Any person may file a complaint about a commercial ambulance service with SOCALR. SOCALR may ask a commercial ambulance service to explain a complaint before SOCALR takes further action on it. A complaint not covered by this subtitle may be referred by SOCALR to other appropriate parties for investigation and action. A commercial ambulance service shall: Send SOCALR any written complaint made to the commercial ambulance service alleging a potential violation of the Maryland Medical Protocols for Emergency Medical Providers within 5 days of receipt by the commercial ambulance service; Send SOCALR within 14 days a written report of the investigation by the commercial ambulance medical director; Notify SOCALR within 72 hours of receiving a written complaint alleging a potential violation of Education Article, §13-515, Annotated Code of Maryland, or this subtitle; Forward applicable complaints within 5 days of receipt; Attach a written explanation of the ambulance service's position on the complaint; and Explain the current status of the complaint. A commercial ambulance service may not retaliate against an employee because the employee: Makes a complaint under this subtitle; or Participates in a proceeding under this subtitle. SOCALR does not have jurisdiction over and may not take action on complaints that relate solely to billing matters. SOCALR may inspect a commercial ambulance service or commercial ambulance and investigate compliance by a commercial ambulance crew member to: Decide whether to issue a license; Ensure the health, safety, or welfare of the persons who utilize commercial ambulance services; or Respond to a complaint. SOCALR may inspect the following to verify eligibility or continued compliance with this subtitle: All premises designated on the application; All commercial ambulances; All required equipment and supplies; The manner of use of required equipment; The manner of operation of the commercial ambulance service; The driver's licenses and health care certification or license issued by MIEMSS for each crew member; and All records regarding the operation of the commercial ambulance service relating to this subtitle, including patient medical records when appropriate. SOCALR may conduct confidential conferences with staff or patients during any inspection or investigation. Upon request by SOCALR, a commercial ambulance service, and its owners, management, employees, or agents, shall, at reasonable times and without delay, allow SOCALR to enter all premises designated on the application or used in the operation of a commercial ambulance service, and all commercial ambulances used by the commercial ambulance service, for the purpose of an inspection or investigation necessary to ensure compliance with this subtitle. Inspections to evaluate eligibility of a commercial ambulance service or a commercial ambulance for a license shall be scheduled with the management of the commercial ambulance service at least 24 hours before the inspection unless otherwise mutually agreed. Inspections to ensure continued compliance with this subtitle do not require advance notice. Inspection Procedure. SOCALR shall: Identify itself at the inspection site; Inform the commercial ambulance service representative of the purpose for the inspection; and Inform the commercial ambulance service representative when the inspection has been completed. SOCALR may inspect a commercial ambulance vehicle at any reasonable time, including whenever it is present at a health care facility or other place of medical care or when picking up, transporting, or discharging any patient. Inspections shall be conducted without impeding patient care or unreasonably delaying patient transport unless, in the judgment of SOCALR, the patient care being rendered is detrimental or is reasonably likely to be detrimental to the patient's health, safety, or welfare. No one may impede SOCALR in conducting lawful inspections necessary to evaluate compliance with this subtitle. SOCALR may, with written permission from a commercial ambulance service's owner, which may include a hold harmless clause, ride on commercial ambulance service calls for the purpose of evaluating compliance with this subtitle. SOCALR may conduct surveys of patients served by a commercial ambulance service to evaluate compliance with this subtitle. SOCALR may take photographs or videos during an inspection or investigation under this subtitle. After the initial investigation, SOCALR may dismiss a complaint or terminate an investigation if it finds the complaint or alleged violation to be: Frivolous; Made in bad faith; Legally or factually insufficient; or Fully resolved to the satisfaction of the SOCALR. If SOCALR finds that a commercial ambulance service, a commercial ambulance, or an individual to whom MIEMSS has issued a certification card or license is believed to have violated this subtitle or an order issued by SOCALR, SOCALR may issue a noncompliance notice. Each noncompliance notice shall: Be in writing; Describe the alleged violation; Reference the provision of this subtitle that the commercial ambulance service or individual is alleged to have violated; State the proposed remedy or corrective action required; Set a reasonable time for abatement and correction of the alleged violation, if applicable; Specify the reporting mechanism that will be required to confirm the remedy, abatement, or correction of the alleged violation; and Specify any proposed disciplinary action to be taken by SOCALR. The noncompliance notice is the final agency action if a party does not timely request a hearing under Regulation .09 of this chapter to contest the noncompliance notice. SOCALR may summarily suspend a license for prohibited conduct under this chapter if the public health, safety, or welfare imperatively requires the emergency action. If a license is summarily suspended under §A of this regulation, SOCALR shall furnish, within 3 business days, to the licensee whose license is temporarily suspended: Written notice of the temporary suspension, including the finding that a temporary suspension was required; The reasons supporting the finding and the temporary suspension; and An opportunity to be heard. The written notice under §B of this regulation shall be: Served personally; or Sent by certified mail to the last known address of the commercial ambulance service. For a hearing on a summary suspension under Regulation .09 of this chapter, certain time periods shall be shortened, as specified in Regulation .09 of this chapter. The summary suspension is the final action if a party does not timely request a hearing under Regulation .09 of this chapter to contest the summary suspension. SOCALR may suspend or revoke a license for acts that violate this chapter. SOCALR may require appropriate remedial action instead of suspension or revocation of a license. The requirements for the remedial action shall: Be written; Set a reasonable time for abatement; and Specify any proposed disciplinary action to be taken by SOCALR for failure to satisfy the requirements of the remedial action. The action taken by SOCALR is the final agency action if a party does not timely request a hearing under Regulation .09 of this chapter to contest the action. Upon the suspension or revocation of a commercial ambulance service license the commercial ambulance service shall immediately: Cease operations with all commercial ambulance vehicles; Make a reasonable effort to cease all recallable advertising; and Surrender to SOCALR all commercial ambulance licenses issued to the commercial ambulance service; and Make all licensed commercial ambulances available to SOCALR for removal of the licensing decal by or under the supervision of SOCALR. Upon the suspension or revocation of a commercial ambulance license, the commercial ambulance service shall immediately: Cease operations with that specific commercial ambulance; and Surrender the commercial ambulance license to SOCALR; and Make the commercial ambulance available to SOCALR for removal of the licensing decal by or under the supervision of SOCALR. Initiation of a Hearing. If an applicant or licensee has a license denied, suspended, or revoked, or wishes to contest a noncompliance notice or remedial action, the applicant or licensee may request a hearing before an administrative law judge by filing a request for a hearing with SOCALR. The request for a hearing must be received by SOCALR not later than 7 calendar days after the applicant or licensee receives the written denial, suspension, revocation, or noncompliance notice. Within 7 calendar days of receiving a request for a hearing, SOCALR shall forward the request to the Office of Administrative Hearings. A hearing shall be scheduled as soon as practical for all parties and the Office of Administrative Hearings but shall be within the following time periods after receipt of the hearing request by SOCALR: For summary suspensions under Regulation .07 of this chapter, 21 calendar days; or For all other hearings, 60 calendar days. Failure of a party to make a timely request to contest a noncompliance notice, remedial action, or denial, suspension, or revocation of a license shall render the action taken the final agency action. Hearing Procedures. A hearing is governed by COMAR Title 28, except as modified in this regulation. For denial of a license, the applicant has the burden of proving, by a preponderance of the evidence, full satisfaction of all requirements and entitlement to the license. For suspensions, revocations, and contested noncompliance or violation notices, SOCALR has the burden of proving, by a preponderance of the evidence, the violation or violations alleged. In a proceeding before an administrative law judge or a court, SOCALR may disclose information that contains or might reveal confidential business information if: The information is relevant to the case at hand; and Before disclosure, the administrative law judge or court that is conducting the proceeding enters an appropriate order to protect confidential business information. Final Decision. The decision of the administrative law judge is final as to all factual matters submitted at the hearing. The Executive Director retains the final decision-making authority on all penalties including denial, suspension, or revocation of a license or required remedial action. The administrative law judge shall render a proposed decision on all factual and legal matters and on the recommended penalty within the following time periods after conclusion of the hearing or after receipt of written closing statements or proposed findings of fact, whichever is later: For summary suspensions under Regulation .07 of this chapter, 21 calendar days; or For all other hearings, 60 calendar days. Exceptions. Any party dissatisfied with the proposed decision of the administrative law judge may file written exceptions with the Executive Director or the Executive Director's designee as provided in this section: Exceptions shall be received by the Executive Director or the Executive Director's designee within 10 calendar days after receipt of the proposed decision by the excepting party, or within 14 calendar days after the date of the proposed decision, whichever is earlier, and copies shall be promptly served on all other parties to the hearing. If exceptions are timely filed, any other party may file opposing or reply comments with the Executive Director or the Executive Director's designee within 10 calendar days of the date of filing of the original exceptions. The party shall promptly serve copies on all other parties to the hearing. If exceptions are timely filed, the Executive Director or the Executive Director's designee shall consider the proposed decision, the exceptions, and any responses to the exception, and the portions of the administrative record as cited by the parties and as considered necessary. The Executive Director or the Executive Director's designee shall render a final written decision without the receipt of any new evidence, but after the opportunity for oral arguments before the Executive Director or the Executive Director's designee. If exceptions are not timely filed, the Executive Director or the Executive Director's designee shall issue a final decision as soon as possible which shall include adoption or modification of the penalty recommended by the administrative law judge. Unless the Executive Director or the Executive Director's designee orders a summary suspension under Regulation .07 of this chapter, any suspension or revocation of a license shall be stayed during the pendency of timely filed and pursued administrative proceedings, but not after a final agency decision. Judicial Review. Final contested case decisions of the Executive Director are subject to judicial review as provided by law. MIEMSS shall be a party to any review. In addition to the civil remedies provided under this subtitle, a person who violates any provision of this subtitle may be prosecuted criminally for commission of a misdemeanor. Upon conviction, a person found guilty of violating any provision of this subtitle is subject to a fine not exceeding $1,000 per violation. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.09 to COMAR 30.09.09, August, 1997 Regulations .01—.05, BLS Service, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.10, Enforcement, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .03J, K amended and L adopted effective October 15, 2004 (31:20 Md. R. 1486) This chapter governs standard commercial ambulance equipment. All commercial ambulance services shall equip operating bases and ambulances as required by this chapter unless the: Commercial ambulance service is specifically excluded from a specific class of commercial ambulance service in a related chapter of this subtitle; or Requirement is waived in writing by SOCALR for a specific commercial ambulance service or a specific commercial ambulance. Additional equipment requirements for ALS and neonatal ambulances are listed in COMAR 30.09.11 and 30.09.12. Greater quantities of supplies and medications shall be added to the ambulance if: The transport time is greater than 30 minutes, and the patient is known to require supplies or medications that exceed the requirements in COMAR 30.09.10—13; or The ambulance is on standby at an event where it can reasonably be expected that there will be more than one patient. Waivers. A commercial ambulance service may request in writing under the requirements of COMAR 30.09.04.08 that SOCALR waive a requirement to carry equipment which is not needed for the service provided. The commercial ambulance service shall bear the burden of demonstrating to SOCALR's satisfaction that the equipment is not necessary. Each operating base shall have: The ability to reliably communicate with the public by telephone; A two-way radio or radiotelephone that will properly communicate with its ambulance within the routine area of operation; and An adequate amount of medical supplies to ensure stock is reasonably proportional to the size of the service and call volume. Each ambulance shall carry the following equipment and supplies: Two C cell or larger, portable hand-lights; One A-B-C rated fire extinguisher of at least 5 pound capacity, securely mounted in a location that is readily accessible to the crew; One 40-channel UHF two-way radio, with the tone codes necessary to communicate with online medical control in Maryland; One two-way radio or cellular telephone that will properly communicate between the ambulance and the ambulance service dispatch center which may be the same radio referenced in §C of this regulation; For ground ambulances, three U.S. Department of Transportation approved reflective road hazard triangles; No Smoking signs in both the patient and driver compartment mounted in a location that is clearly visible to vehicle occupants with letters at least 1 inch tall and 3/4 inch wide; and One copy of the Maryland Medical Protocols for EMS Providers. Each ambulance shall carry the following standard medical supplies: 24 sterile gauze pads at least 3 inch by 3 inch; Three rolls of 2-inch hypoallergenic adhesive tape; Three rolls of 1-inch hypoallergenic adhesive tape; 12 cravats or triangular bandages; 12 rolls of 4-inch self-adjusting gauze bandages; Four chemical cold packs; One box of assorted, plastic, bandage strips; Six clean individually wrapped sanitary napkins or other highly absorbent sterile dressing; Five sterile trauma dressings, 5 inches by 9 inches minimum; Two tongue depressors; Two tubes of glucose supplement; One 30 milliliter vial of ipecac or equivalent; One 100 gram bottle of activated charcoal with or without sorbitol; Adult 0.3 milligram epinephrine auto-injector; Pediatric 0.15 milligram epinephrine auto-injector; One penlight; One piece of nonadherent material for occlusive dressing, 18 inches by 25 inches minimum (metal foil not acceptable); Two burn sheets; Two emesis basins; One pair of all purpose utility scissors; One container of disinfectant meeting the requirements of 29 CFR §1910.1030; One box of facial tissue or roll of toilet tissue; Six Maryland triage/treatment tags, with color-coded plastic ribbon in: Red, Yellow, Green, and Black; One sterile commercially packaged obstetrical (OB) kit containing: One large towel or receiving blanket, One pair of sterile gloves, Two umbilical clamps or ties, One bulb syringe, and One pair of sterile scissors or scalpel; One bed pan; One urinal; Four leak proof bags of at least 3 millimeter thick which are: Red, or Marked with the universal biohazard symbol conforming to 29 CFR §1910.145; One receptacle to safely dispose of needles, glass, or other sharp material; and One CPR board or equivalent. Each ambulance shall be equipped with one: Onboard suction unit which is: Powered by a reliable source from: The engine manifold, or An electrically powered vacuum pump; Capable of developing a: Vacuum pressure equivalent to at least 300 mm Hg within 4 seconds of clamping, and Free air flow of at least 20 liters/minute at the end of the collection tube; Adjustable in suction force for use in children and intubated patients; Equipped with wide bore tubing; Equipped with one rigid pharyngeal suction tip; and Equipped with two suction catheters with integral thumb controls in assorted sizes appropriate for the patients being transported including at least one size from among: 6, 8, 10, or 12 French catheter, and 14, 16, or 18 French catheter; and Portable suction unit which is: Capable of operating continuously under suction for at least 20 minutes while independent of alternating current; Capable of developing: A vacuum pressure equivalent to 300 mm Hg within 4 seconds of clamping, and A free air flow of at least 20 liters/minute at the end of the suction tube; Equipped with wide bore tubing; Equipped with one rigid pharyngeal suction tip; and Equipped with two suction catheters with integral thumb controls in sizes appropriate for the patients being transported including one size from among: 6, 8, 10, or 12 French catheter, and 14, 16, or 18 French catheter. Each ambulance shall carry a portable kit containing the following medical supplies: 12 sterile gauze pads at least 3 inches by 3 inches in size; Two rolls of 2-inch hypoallergenic adhesive tape; Eight cravats or triangular bandages; One set of oropharyngeal airways in adult, child, and pediatric sizes; One stethoscope; One adult blood pressure cuff; One pediatric blood pressure cuff; One pair of all purpose utility scissors; One penlight; Six rolls of 4-inch self-adjusting gauze bandages; Four sterile trauma dressings at least 5 inch by 9 inches in size; One marking pen; and 12 exam gloves which meet the requirements of 29 CFR §1910.1030. The portable kit shall be: Dust and moisture resistant; Large enough to carry the required items; and Organized so items are readily accessible. Each in-service ambulance shall carry at least one automated external defibrillator. Each ambulance shall carry the following standard airway maintenance and ventilation equipment: Oxygen which meets the following criteria: For ground ambulances: Optional onboard cylinders for BLS ambulances have a capacity of at least 3,000 liters; Portable cylinders have a capacity of at least 400 liters; The following number of cylinders, if on-board oxygen is present, unless more are needed for a particular patient based on COMAR 30.09.07.03A(2)(g): One E size, One jumbo D size, or Two D size; The following number of cylinders, if on-board oxygen is not present, unless more are needed for a particular patient based on COMAR 30.09.07.03A(2)(g): Two E size, Two jumbo D size, or Three D size; For air ambulances: An on-board oxygen system that meets the CAMTS standards, which provide that: Oxygen is installed according to FAA regulations; Medical transport personnel can determine if oxygen is on by in-line pressure gauges mounted in the patient care area; Each gas outlet is clearly marked for identification; Oxygen flow can be stopped at or near the oxygen source from inside the aircraft; The indicators for quantity of oxygen remaining and measurement of liter flow are accessible to medical transport personnel while enroute; and Oxygen flow meters and outlets must be padded, flush mounted, or so located to prevent injury to medical transport personnel; and A minimum of one portable oxygen cylinder that has a capacity of at least 400 liters; All cylinders are properly color coded for U.S.P. grade, medical oxygen; The system is free of: Grease, Oil, or Other flammable organic material; and All cylinders have passed hydrostatic testing during the past: 5 years, or 10 years, if approved by the inspector based on the condition of the cylinder; Regulators which: Have a reducing valve limiting line pressure to 50 10 psi; Have a pressure gauge, with a range of 0 to 2,500 psi, to indicate the pressure of oxygen remaining in the cylinder; Are capable of delivering at least 0 to 15 liters/minute flow in calibrated increments; Are accurate to within 1 liter/minute when at a setting equal to or less than 5 liters/minute; Are accurate to within 1.5 liters/minute when at a setting between 6 and 10 liters/minute; and Are accurate to within 2 liters/minute when at a setting equal to or greater than 11 liters/minute; At least one flow smeter dedicated to the portable oxygen system that is not gravity dependent; If present, positive pressure demand valves which provide: 100 percent oxygen; An instantaneous flow rate not greater than 40 liters/minute; An inspiratory pressure relief valve that opens at 60-centimeter water pressure; and A 15/22-millimeter fitting; Adult oxygen administration sets which are the following types and quantities: Four non-rebreather; Two venturi; Six nasal cannula; Disposable, single use design; and Transparent; Pediatric oxygen administration sets which are the following types and quantities: Two non-rebreather; Two nasal cannula; Disposable, single use design; and Transparent; Two sets of oxygen connecting tubing; One hand operated, self-reinflating adult bag valve mask with: Oxygen inlet; Reservoir tube; Transparent face mask; and Selectable pop off valve or no pop off valve; One hand operated, self-reinflating, pediatric bag valve mask with: Oxygen inlet; Reservoir tube; One transparent neonatal face mask; and One transparent pediatric or child face mask; One pocket mask with one-way valve; and One set of oropharyngeal airways in the following sizes: Adult; Child; and Infant. Each ambulance shall carry the following standard equipment for carrying patients: One ambulance stretcher that: Is adjustable in height, Permits the elevation of the upper body, Has a mattress covered with nonabsorbent material free from defects, such as rips and tears, Has safety straps to secure the patient in accordance with the manufacturer's recommendations, and Has a stretcher-mounted IV pole or equivalent; and One folding stair chair capable of negotiating narrow hallways or stairways. Each ambulance shall carry the following fracture immobilization equipment: One full spinal immobilization board for transportation or equivalent; One half spinal immobilization device; One orthopedic or clamshell stretcher or equivalent; Three 9-foot straps with buckles; Two long padded board splints approximately 54 inches by 3 inches; Two medium padded board splints approximately 36 inches by 3 inches; Two short padded board splints approximately 15 inches by 3 inches; and Rigid extrication collars in the following adult sizes: Two adjustable; or One of each of the following: Medium (regular), Small (short), and Extra small (no-neck or neckless). Equipment or supplies required to protect personnel during the performance of their duties shall be carried in each commercial ambulance vehicle licensed under this subtitle. The quantities and specifications of the equipment and supplies required in this chapter shall meet at least the requirements set by the Maryland Occupational Safety and Health. Each ambulance shall carry the following personal protective equipment supplies: Adequate quantities of exam gloves in: Uni-size; or All of the following: Small, Medium, and Large; Two pair non-absorbent gowns per crew member; Two surgical masks per crew member; One pair safety goggles per crew member; One particulate (TB) mask per crewmember; and At least 4 ounces of waterless hand cleaner. Each ambulance shall carry the following linen supplies: Two pillows covered with nonabsorbent material or disposable; Four cloth or disposable pillow cases; Four cloth or disposable sheets; and Two blankets. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Regulation .04 adopted as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); emergency status expired July 6, 1997 Regulation .04 adopted permanently effective July 7, 1997 (24:10 Md. R. 711) Chapter recodified from COMAR 14.22.10 to COMAR 30.09.10, August, 1997 Regulation .04A amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1189); amended permanently effective October 5, 1998 (25:20 Md. R. 1534) Regulations .01—.04, ALS Service, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.13, Standard Commercial Ambulance Equipment, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02 amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .04E amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .05 amended effective October 15, 2004 (31:20 Md. R. 1486) Regulation .09A, C amended effective October 15, 2004 (31:20 Md. R. 1486) This chapter defines additional requirements for ALS services. An ALS commercial ambulance service shall retain at least one licensed paramedic to function as an ALS coordinator who: Is approved by the ALS service medical director; Participates on the ALS service's quality review committee; and Oversees: ALS operations; and The submission of patient care reports and EMS data in accordance with COMAR 30.03.04.04. An ALS commercial ambulance service may provide BLS service with an ambulance licensed as either: ALS; or BLS. An ALS commercial ambulance service may not provide scheduled ALS service with a BLS-licensed commercial ambulance vehicle unless: It uses a BLS-licensed ambulance for a period of not more than 30 calendar days for reasons related to: Routine maintenance; or Mechanical failure of an ALS-licensed commercial ambulance vehicle; The BLS-licensed ambulance has, in addition to the equipment required in COMAR 30.09.10, all the equipment required in this chapter; and It has notified SOCALR of the proposed use before its occurrence and has been issued a confirmation number verifying authorization. In addition to the equipment required under COMAR 30.09.10, the following equipment and supplies shall be carried in commercial ambulances licensed to provide ALS service: An onboard oxygen system that meets the requirements of COMAR 30.09.10.09; Cardiac monitoring/defibrillating/transcutaneous pacing equipment including: One monitor/defibrillator which has: Direct current capability, Paper print out capability, Synchronized cardioversion and unsynchronized defibrillation, Two adult and one pediatric defibrillator pads, Defibrillator pads with quick look capability, One set of EKG leads, and Transcutaneous pacing; and Supplies related to EKG monitoring to include the following items: 18 ECG electrodes, Spare set of EKG leads or equivalent, Spare monitor/defibrillator batteries, Two spare EKG paper rolls, Two adult transcutaneous pacing pads, One pediatric transcutaneous pacing pad, and One tube of electrode paste or two packages of electrolyte pads for use in defibrillation; Medications including: All the medications listed in the Maryland Medical Protocols for Emergency Medical Services Providers in sufficient quantities to treat and care for each patient that they respond to and care for; Sufficient quantities to provide: At least the maximum dosage for one 100 kilogram patient for a period of 30 minutes, or An adequate quantity to treat and care for the patient if the transport time is expected to exceed 30 minutes; Controlled substances which are stored in a controlled access system acceptable to SOCALR; and Two nebulizers for medication administration; Intravenous equipment and supplies including: Two 16 gauge 1 1/4 to 1 1/2 inches long intravenous catheters with needles; Two 18 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles; Two 20 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles; Two 22 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles; Two 24 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles; Two 10 or 20 drops/milliliter or equivalent intravenous administration sets; Two 60 drops/milliliter or equivalent intravenous administration sets; Two 1000 cubic centimeter bags or equivalent of Ringer's lactate intravenous solution; Site preparation materials; and Roof-mounted hooks for hanging intravenous solutions; Parenteral administration equipment including: Four 1 milliliter syringes with 25 gauge needles; Four 3—5 milliliter syringes with 1-inch, 18—21 gauge needles for IM injection; Four 10 milliliter syringes; and Four 18, 19, or 20 gauge needles; Blood specimen collection equipment including: Two red top blood tubes; Two purple top blood tubes; and Two vacutainer barrels; Ventilation and airway maintenance equipment including: Laryngoscope equipment and supplies: One of each size 0, 1, 2, 3, and 4 Miller laryngoscope blades, One of each size 1, 2, 3, and 4 MacIntosh laryngoscope blades, and One each adult and pediatric laryngoscope handles; Endotracheal tubes: One of each size 6, 7, 8, and 9 millimeter cuffed, and One of each size 2.5, 3, 3.5, 4, and 5 millimeter uncuffed; One adult flexible stylette; One pediatric flexible stylette; One roll of 1-inch adhesive tape; One 10 milliliter syringe; One pair adult McGill forceps; One pair pediatric McGill forceps; One 4-ounce tube or four 3-gram packets of water soluble surgical lubricant; One spare laryngoscope bulb for both MacIntosh and Miller blades; One spare set of laryngoscope batteries for both adult and pediatric handles; and One end title carbon dioxide (ETCO2) detector. One direct current to alternating current inverter power supply capable of providing proper wattage to power equipment used on an ALS ambulance; and Miscellaneous equipment and supplies as follows: One glucometer; One pulse oximeter for each in-service ALS ambulance; and One current, printed within last 2 years, copy of a drug reference. An ALS-licensed ambulance may not transport an obstetrical patient from one hospital to another for a higher level of obstetrical care unless: The admitting hospital: Is a perinatal center; Before designation of perinatal centers by the EMS Board, has a certificate of need issued by the Maryland Health Resources Planning Commission for its neonatal intensive care unit or approval from the Health Services Cost Review Commission for a neonatal intensive care cost center; or Before the EMS Board has completed the process of entering into an agreement with an out-of-State hospital to serve as an out-of-State perinatal referral center, possesses all government approvals required to operate a neonatal intensive care unit under the laws of the jurisdiction in which it is located including, if required, a certificate of need and all necessary licenses; The additional equipment required under §B of this regulation is onboard; and In addition to the staffing required under COMAR 30.09.07.02A(4), there is a registered nurse or physician experienced in the care of obstetrical patients onboard. Equipment Requirements. The additional equipment required under §B(2) of this regulation may be provided by the referring or admitting hospital and shall be onboard when transporting an obstetrical patient. In addition to the equipment required under COMAR 30.09.10 and this chapter, the following shall be onboard: One doppler; One reflex hammer; One neonatal bag valve mask with manometer and newborn and premature infant size masks; One IV infusion pump; and The following medications: Four vials oxytocin (10 units/milliliter); Two vials methergine (0.2 milligram/milliliter); Two vials 10 percent calcium gluconate (10 milliliters); Three vials terbutaline (1 milligram/milliliter); and Eight vials 50 percent magnesium sulfate (10 milliliters). Additional Record Keeping Requirements. In addition to the requirements in COMAR 30.09.08, the following information shall be documented on the patient report: Name of the referring hospital; Name of the referring physician; Name of the receiving hospital; Name of the receiving physician; Names and license or certification level of the commercial ambulance driver and commercial ambulance personnel; Time the request for transport was received by the commercial ambulance service; Time en route to the referring hospital; Time of arrival at the referring hospital; Time of departure from the referring hospital; Time of arrival at the admitting hospital; Maternal gestational age; Reason for transport; and Care provided during transport. Patient care reports and EMS data shall be submitted in accordance with COMAR 30.03.04.04. The additional requirements for obstetrical transports listed in §§A and B of this regulation may be waived when an ALS-licensed commercial ambulance is transporting an uncomplicated obstetrical patient from a hospital without an obstetrical service. A licensed commercial ambulance service may not provide specialty care transport unless: Licensed as a specialty care transport ambulance service; or No more than ten times a year, if a licensed specialty care transport ambulance service is not available within a clinically reasonable time as determined by the referring physician: The sending facility provides health care personnel authorized by law to provide the level of care required by the patient during transport, which may include a nurse meeting the requirements of COMAR 10.27.09.04C(2); Required specialty equipment is available; The ambulance used is licensed as at least an ALS ambulance; Notice is made to SOCALR within 24 hours of the transport; and A report, reviewed and signed by the medical director, is submitted to SOCALR within 7 days of the transport, documenting the patient’s condition, the care rendered, crew configuration and efforts made by the referring physician, and the service to secure appropriate SCT resources. Education Article, §13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Regulation .02 repealed and new Regulations .02—.06 adopted as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); adopted permanently effective July 7, 1997 (24:10 Md. R. 711) Chapter recodified from COMAR 14.22.11 to COMAR 30.09.11, August, 1997 Regulation .02F amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1189); amended permanently effective October 5, 1998 (25:20 Md. R. 1534) Regulations .01—.06, Specialized Service, repealed and new Regulations .01—.05, ALS Service, adopted effective January 10, 2000 (26:27 Md. R. 2017) Regulation .02A amended effective November 1, 2010 (37:21 Md. R. 1437); December 12, 2013 (40:24 Md. R. 2017) Regulation .03 amended effective January 15, 2005 (31:26 Md. R. 1866) Regulation .04C amended effective November 1, 2010 (37:21 Md. R. 1437) Regulation .05 repealed and new Regulation o5 adopted effective January 15, 2005 (31:26 Md. R. 1866) Regulation .05B amended effective September 1, 2014 (41:17 Md. R. 971) This chapter governs the operations of neonatal ambulance services and neonatal ambulances. A commercial ambulance service wishing to provide neonatal ambulance services shall comply with the requirements of this chapter in addition to the other applicable requirements of this subtitle. An ambulance service transporting neonates shall obtain a neonatal commercial ambulance service license. An applicant for a neonatal commercial ambulance service license shall submit an application to SOCALR on the required form. A completed application form shall be accompanied by documentation which states to SOCALR’s satisfaction that the commercial ambulance service has: Retained two or more registered nurses who: Meet the requirements of the Board of Nursing under COMAR 10.27.09.04 to provide nursing care to neonates during interfacility transport; and Agree to assume responsibility for patient care during the transport process; Retained one or more physicians who are board certified or are active candidates for board certification in neonatology who: Possess current knowledge of the Maryland EMS System as required in COMAR 30.03.03.03B(4), as well as current knowledge of: The effects of transport on the neonate; and The operation of neonatal transport equipment and ambulance communications equipment; and Working with a neonatal or perinatal center, agree to: Serve as medical director for the neonatal service; Provide medical direction to the commercial ambulance service's personnel-related neonatal care; Provide training as required in neonatal care; and Participate in a quality assurance program; and If providing neonatal transport services in partnership with a hospital-based neonatal intensive care unit, a written MOU stating that all equipment and medications required to transport a neonate under this chapter will be readily available to the service. A licensed neonatal commercial ambulance service shall immediately advise SOCALR of any change in the medical director named in §D(2) of this regulation. A licensed neonatal commercial ambulance service may not transport a neonate from one hospital to another for a higher level of care unless the admitting hospital: Is a perinatal center; Is a neonatal center; Before designation of perinatal centers by the EMS Board, has a certificate of need issued by the Maryland Health Resources Planning Commission for its neonatal intensive care unit or approval from Maryland Health Resources Planning Commission for a neonatal intensive care unit; or Before the EMS Board has completed the process of entering into an agreement with an out-of-State hospital to serve as an out-of-State perinatal referral center, possesses all government approvals required to operate a neonatal intensive care unit under the laws of the jurisdiction in which it is located including, if required, a certificate of need and all necessary licenses. Neonates. Neonates being transferred to a neonatal intensive care unit (NICU) shall be transported by a neonatal licensed transport service, as described in Regulation .04 of this chapter. Neonates being transferred to any acute care setting other than a NICU shall be transported by either: A neonatal licensed transport service; or A specialty care transport (SCT) service with an RN who has age-appropriate competencies and equipment. Infants. Infants being transferred to any acute care setting shall be transported by: A neonatal licensed transport service; An SCT service with a staff who has age-appropriate competencies and equipment; or An ALS unit that includes staff with age-appropriate competencies and equipment, only after a neonatal licensed transport or SCT service has reviewed the case and referred it to the ALS service. Neonates or Infants being transported for convalescent care at a rehabilitation hospital or long-term facility shall be transported by: A neonatal licensed transport service; An SCT service with a staff who has age-appropriate competencies and equipment; or An ALS unit that includes staff with age-appropriate competencies and equipment, only after a neonatal licensed transport or SCT service has reviewed the case and referred it to the ALS service. An applicant for a neonatal commercial ambulance license shall submit an application to SOCALR. A licensed neonatal commercial ambulance service may only provide neonatal transport service with an ALS or SCT licensed commercial ambulance that meets all the requirements of this chapter. A licensed neonatal commercial ambulance service shall ensure the patient is secured in a patient restraint device appropriate for the patient’s age and weight. A licensed commercial ambulance, when providing neonatal service, shall be staffed by: A driver who meets the requirements in COMAR 30.09.07.02A(4)(a); and At least two individuals, in addition to the driver: At least one of whom shall be a registered nurse or physician with advanced training in the care of neonates; and The second individual shall be a Maryland licensed health care provider, including a physician, registered nurse, respiratory therapist, nurse practitioner, physician assistant, paramedic, or CRT, who is medically qualified to care for the patient and has additional training needed to care for neonatal patients during interfacility transport including: Knowledge of the Maryland EMS System; The effects of transport on the neonate; and The operation of neonatal transport equipment and ambulance communications equipment. When more than one patient is transported simultaneously in the same ambulance: There shall be at least one registered nurse or physician with advanced training in the care of neonates present for each neonatal patient; and Each patient shall be secured in a separate patient restraint device appropriate for the patients age and weight. All personnel attending to neonatal patients shall: Prior to transporting neonatal patients, successfully complete: The Neonatal Resuscitation Program; and The S.T.A.B.L.E. Program; Maintain a current: Neonatal Resuscitation Program Provider Course Completion Card; and S.T.A.B.L.E. Program Completion Certificate; and If a physician: Maintain board certification in neonatology; Maintain board certification in pediatric critical care; or Be a licensed physician serving in the second or third year of a neonatology or pediatric critical care fellowship. In addition to the information required in COMAR 30.09.08, the following information shall be documented on the patient runsheet: Mother's name; Name of the referring hospital; Name of the referring physician; Name of the receiving hospital; Name of the receiving physician; Date of birth; Time of birth; Gestational age of the patient; Weight of the patient; Primary reason for transport; Names and license or certification level of the commercial ambulance driver and all personnel; Time the request for transport was received by the commercial ambulance service; Time the transport team departed from base; Time the transport team arrived at the referral hospital; Time the transport team departed from the referral hospital; Time the transport team arrived at the receiving hospital; and Care provided during the transport. A copy of the runsheet and all documentation of patient care during the transport shall be submitted in accordance with COMAR 30.09.08.06D. A licensed neonatal commercial ambulance service shall have a quality assurance program required by COMAR 30.03.04 which shall include: A review by registered nurses and physicians of patient care provided during neonatal transport; A review by the program medical director of each specialty care transport: Requiring a change in the plan of care during transport; In which the patient’s condition worsened during transport; Requiring a change in destination during transport; or During which there was an unexpected outcome or event; Written documentation of reviews of neonatal transports which shall be available to SOCALR upon request; and A quality assurance process for call taking, call screening, and dispatch. A licensed neonatal commercial ambulance service shall comply with COMAR 30.09.11.03 when transporting a neonate. There shall be a written maintenance plan for all medical devices used on neonatal commercial ambulances approved by SOCALR, which shall provide that: All specialized medical devices used during transport shall: If provided by the hospital, be maintained by the hospital; or If provided by the licensed commercial ambulance service, be maintained as recommended by the manufacturer; and The licensed commercial service providing specialized medical devices used during transport shall maintain records documenting maintenance and repair services. All on-board medical devices shall be secured to the satisfaction of SOCALR. The following equipment shall be carried in a neonatal ambulance: All equipment listed in the current Neonatal equipment list approved by SOCALR; Any additional equipment required for the care of the patient as determined by consultation between the referring and receiving physicians; and Additional medications approved for use by the neonatal service medical director to meet the needs of the types of patients being transported. A list of the additional medications used by the neonatal service and approved by the neonatal service medical director shall be provided to SOCALR and approved by the State EMS Medical Director annually upon license renewal, and shall be available on each ambulance when in use for a neonatal transport. SOCALR shall be notified in writing of any changes to the list of additional medications used by the neonatal transport service within 7 days of the change. There shall be sufficient quantities of medications to care for one neonatal patient for the longer of: 1 hour; or Two times the estimated time of transport. Education Article, §13-515, Annotated Code of Maryland Effective date: October 12, 1992 (19:20 Md. R. 1816) Chapter recodified from COMAR 14.22.12 to COMAR 30.09.12, August, 1997 Regulations .01—.08, Enforcement, repealed effective January 10, 2000 (26:27 Md. R. 2017) Regulations .01—.07, Neonatal Ambulance Service, adopted effective January 10, 2000 (26:27 Md. R. 2017) Chapter revised effective September 1, 2014 (41:17 Md. R. 972) Regulation .02 amended effective May 3, 2021 (48:9 Md. R. 361) Regulation .03 amended effective May 3, 2021 (48:9 Md. R. 361) Regulation .04A amended effective May 3, 2021 (48:9 Md. R. 361); October 16, 2023 (50:20 Md. R. 889) Regulation .04C amended effective October 16, 2023 (50:20 Md. R. 889) Regulation .05B amended effective May 3, 2021 (48:9 Md. R. 361) Regulation .06 amended effective May 3, 2021 (48:9 Md. R. 361) This chapter governs the requirements for a commercial air ambulance service. To be licensed as a commercial care air ambulance service, a commercial air ambulance service shall comply with the requirements of this chapter in addition to the other applicable requirements of this subtitle. An applicant for a commercial air ambulance service license shall submit an application to SOCALR on the required form. An applicant for a commercial air ambulance service license shall: Be accredited by CAMTS; or If ineligible to apply for CAMTS accreditation, because it has been in service for less than 1 year: Submit to SOCALR a CAMTS consultation report indicating compliance with the CAMTS standards; and Apply for and receive full CAMTS accreditation within 18 months of being licensed by SOCALR. A licensed commercial air ambulance service shall notify SOCALR within 24 hours of any change in CAMTS accreditation status and the reason for the change. A licensed commercial air ambulance service may provide ALS, critical care, or neonatal transport service, or any combination of these, if: The equipment and personnel requirements of this subtitle are met for the specific type of transport; The submitted service license application includes the information required, demonstrating compliance for the specific type of transport; and The service is accredited by CAMTS at that level. A licensed commercial air ambulance service may not provide services with an unlicensed air ambulance unless: The unlicensed air ambulance is used as a temporary replacement for a licensed air ambulance that is out of service for routine maintenance or repair; The temporary replacement air ambulance meets all FAA requirements; The temporary replacement air ambulance has all required staffing and equipment; and It has notified SOCALR of the use of the replacement air ambulance and provided the following information: The unit designation number assigned for operational purposes; The FAA registration number; and The make, model, and year of manufacture. A licensed commercial air ambulance service that provides services with an unlicensed air ambulance shall notify SOCALR when the licensed air ambulance is returned to service. A commercial air ambulance shall be staffed by: A pilot who meets the requirements of licensure established by the Federal Aviation Administration 14 CFR Parts 61, 67, and 135; and At least two additional individuals who meet or exceed the requirements for CAMTS accreditation at the level which the service is providing. Each air ambulance shall carry sufficient equipment and supplies listed in COMAR 30.09.10—13 to assure: The ability to carry out all procedures in the Maryland Medical Protocols for EMS Providers; and That when transporting specialty care patients, the additional equipment necessary to care for the patient being transported is available; A list of medical equipment and supplies will be provided to SOCALR with the licensing application. All medical, communications, and associated equipment on-board: If routinely carried, shall be EMI certified for air operations; or If not routinely used, shall be approved by the pilot. Pilots of rotary wing air ambulances shall remain with the aircraft when the aircraft is occupying a hospital helipad with room for landing a single aircraft. SYSCOM shall coordinate the landing sequence of multiple emergency medical services aircraft in consultation with the pilots-in-command based on patient priority. Commercial air ambulance services shall: Comply with the requirements of COMAR 30.07; and Keep SYSCOM apprised of the location of their air ambulance at all times while the aircraft is in Maryland or in geographic proximity to the Maryland border in a contiguous state. Education Article, §§13-508 and 13-515, Annotated Code of Maryland Effective date: October 15, 2004 (31:20 Md. R. 1486) This chapter governs the requirements for a specialty care transport commercial ambulance service other than neonatal ambulance services. The requirements for neonatal ambulance services are in COMAR 30.09.12. To be licensed as a specialty care transport commercial ambulance service, a commercial ambulance service shall comply with the requirements of this chapter in addition to the other requirements of this subtitle. An applicant for a specialty care transport commercial ambulance service license shall submit an application to SOCALR on the required form. A licensed specialty care transport commercial ambulance service shall retain one or more medical directors as required by COMAR 30.03.03. In addition to the qualifications in COMAR 30.03.03, the medical director for a specialty care service shall: Have educational experience in the care of the types of critically ill patients the service is transporting; Be board-certified in an appropriate specialty; Be actively practicing within a hospital clinical setting; and Use the following consultants when appropriate: Designated specialty physicians; or The patient's receiving physician. The medical director for a licensed specialty care transport ambulance service shall participate in the development and implementation of any patient care guidelines required for interfacility transport of critically ill patients, including those guidelines to be followed by nursing personnel. A licensed specialty care ambulance service shall immediately advise SOCALR of any change in medical directors. A licensed specialty care ambulance service shall retain one or more registered nurses or nurse practitioners who: Are licensed by the Maryland Board of Nursing; Have knowledge of content which includes, but is not limited to: The transport arena (including transport team membership and role responsibility); Regulations governing COMAR 10.27.09; Documentation; Coordination with other transport team members; Knowledge and skill set appropriate to the client to be transported; Review of safety standards specific to the transport environment; Relevant components of the MIEMSS Base Station Course; Review of the MIEMSS Interhospital Transfer Resource Manual; Risk/benefit ratio assessment and triage decision-making process; Age-appropriate advanced life saving procedures, complications associated with procedures, and complications associated with delay in intervening with any of the procedures; Respiratory monitoring including differentiation between upper and lower airway obstruction, covert and overt signs of respiratory failure, and airway management; Neurological and spinal cord emergences and monitoring; Cardiovascular and hemodynamic monitoring including dysrhythmia recognition and pertinent laboratory data and interpretation; Blood and blood product administration; Knowledge of MIEMSS Maryland Medical Protocols for EMS Providers appropriate to the client population transported; Age-appropriate care algorithms and protocols; The responsibilities and accountability of the registered nurse to serve as team leader in absence of the physician; Insuring a safe environment and operational issues related to transport, including rapid egress from a trauma incident; Transport safety, which includes, but is not limited to: Safety briefing related to the vehicle; Protective clothing; and Mission profile; Demonstrate knowledge of the EMS system by: Completing a MIEMSS-approved base station course; or Being a currently licensed EMS provider; Comply with the requirements of COMAR 10.27.09; Screen all requests for specialty care transport; and Determine, in collaboration with the referring physician and program medical director, and in accordance with Regulation .04 of this chapter, the appropriate transport team configuration required for the patient. The licensed specialty care ambulance service shall credential any registered nurse retained by the service to ensure the registered nurse meets the requirements of §G of this regulation. A licensed specialty care commercial ambulance service shall have a quality assurance program required by COMAR 30.03.04 which shall include: A review by registered nurses and physicians of patient care provided during specialty care transport; A review by the program medical director or designated specialty physician of each specialty care transport: Requiring a change in the plan of care during transport; Whose condition worsened during transport; In which there was a change of destination during transport; or In which there was an unexpected outcome or event; Written documentation of reviews of specialty care transports which shall be available to SOCALR upon request; Patient feedback on outcomes to the sending facility; and A quality assurance process for call taking, call screening, and dispatch. The interior configuration of an ambulance used for specialty care transport shall: Allow medical personnel access to the airway and at least one side of the patient from a secured, seat-belted position; Allow medical personnel to see all monitor read-outs from secured, seat-belted positions; Have all medical devices, supplies, and equipment stowed or adequately fastened to prevent items from becoming projectiles that can cause injury in an abrupt stop or crash; and Have compartments used to carry heavy objects, including oxygen cylinders, suction units, intravenous pumps, monitors, or ventilators, with positively locked latches designed to remain closed in an abrupt stop or crash with both latch and hinge bolted to the door and frame structure. A licensed specialty care transport ambulance service may provide specialty care transport using: A dedicated licensed specialty care ambulance; or An ALS licensed ambulance staffed and equipped as a specialty care ambulance. An ambulance providing specialty care transport service shall be staffed as provided in this regulation. If the care required is within the scope of practice of Specialty Care Paramedic and the patient requires no more than one specialty care intervention, as defined in the Maryland Medical Protocols for Emergency Medical Services: A driver who meets the requirements of COMAR 30.09.07.02A(4)(a); and A Specialty Care Paramedic. If the care required is within the scope of practice of a Specialty Care Paramedic and the patient requires two or more specialty care interventions, as defined in the Maryland Medical Protocols for Emergency Medical Services: A driver who meets the requirements of COMAR 30.09.07.02A(4)(a); At least one individual who is: A Specialty Care Paramedic; or A registered nurse with advanced training and certification in the care of specialty care patients and current knowledge of the EMS system as defined in Regulation .02G(3) of this chapter; and At least one individual who: Is one of the following: A CRT initially licensed after July 1, 2001 or who has completed the CRT update program; A paramedic; or If the individual under §C(2) of this regulation is a Specialty Care Paramedic and one of the specialty care interventions involves ventilator management, a respiratory therapist; and Has successfully completed an orientation to specialty care transport. If the care required is outside the scope of practice of a Specialty Care Paramedic: A driver who meets the requirements of COMAR 30.09.07.02A(4)(a); and At least two additional individuals who meet the following requirements: One shall be at least: A Specialty Care Paramedic; or A paramedic who has successfully completed an orientation to specialty care transport; and One shall be a registered nurse, physician assistant, or physician with advanced training and certification in the care of specialty care patients and current knowledge of the EMS system as defined in Regulation .02G(3) of this chapter. If an SCT service is not able to provide a staffed and equipped SCT ambulance within a clinically reasonable time as determined by the referring physician, it may conduct the SCT transport if: The sending facility provides health care personnel authorized by law to provide the level of care required by the patient during transport, which may include a nurse meeting the requirements of COMAR 10.27.09.04C(2); Required specialty equipment is available; The ambulance used is licensed as at least an ALS ambulance; Notice is made to SOCALR within 24 hours of the transport; and A report, reviewed and signed by the medical director, is submitted to SOCALR within 7 days of the transport, documenting the patient’s condition, the care rendered, crew configuration and efforts made by the referring physician, and the service to secure appropriate SCT resources. The paramedic shall provide documentation to the licensed commercial ambulance service that they have successfully completed a specialty care transport course that meets the requirements of COMAR 30.04.03. The medical director is responsible for credentialing the paramedic as required in COMAR 30.03.03.06. The paramedic shall receive at least 36 hours of specialty care continuing education every 3 years. The specialty care ambulance service shall maintain documentation on file for each individual providing patient care including: Annual review of clinical competency in the skills required for the type that are transported; and Proof of training on the use of the equipment necessary to care for and transport the patient, including those items in Regulation .04 of this chapter. All specialized medical devices used during transport shall: If provided by the hospital, be maintained by the hospital; or If provided by the licensed commercial ambulance services be maintained as recommended by the manufacturer. The licensed commercial service providing specialized medical devices used during transport shall maintain records documenting maintenance and repair services. There shall be a means of communicating directly with the consulting specialty care physician and medical director. All on-board medical devices shall be secured. In addition to the equipment required in COMAR 30.09.10 and 30.09.11, the following shall be carried in a licensed ambulance when providing specialty care and shall be age and weight appropriate for the patient being transported: A means of blending oxygen and air to deliver varying concentrations of medical oxygen; One portable electric suction unit which: Meets the criteria in COMAR 30.09.10.06B; and Is adjustable down to 60 millimeters mercury (Hg); Intravascular Equipment and Supplies: Four infusion pumps or equivalent; Six intravenous (IV) pump tubing sets; Six extension sets; Eight stopcocks; Two blood infusion sets; Two intravenous (IV) filters; Eight total needles of assorted sizes ranging from 22 gauge to 18 gauge; When transporting adult patients: Two 1,000 cubic centimeter bags or equivalent of normal saline or Lactated Ringer's Solution; Two 1,000 cubic centimeter bags or equivalent of maintenance intravenous solution; and Twelve total syringes of assorted sizes ranging from 1 cubic centimeter to 60 cubic centimeters; When transporting pediatric patients: Two 250 cubic centimeter bags or equivalent of normal saline or Lactated Ringer's Solution; Two 250 cubic centimeter bags or equivalent of maintenance intravenous solution; and Twelve total syringes of assorted sizes ranging from 1 cubic centimeter to 2 cubic centimeters; Ventilation and airway maintenance equipment and supplies capable of at least the following: Oxygen concentrations between 21 and 100 percent; Peak pressures between 0 and 99; Adjustable inspiratory time; Selectable intermittent mandatory ventilation (IMV); Positive end expiratory pressure (PEEP) between 2—15 centimeters of water; Adjustable ventilatory rates between 0 and 60 breaths per minute; Adjustable tidal volume for adult patients between 200 milliliters and 1,000 milliliters or greater; Adjustable tidal volume for pediatric patients as low as 50 milliliters; Adjustable high and low pressure alarms; and Two ventilator circuits; Monitoring Equipment: One cardiac monitor which meets the criteria of COMAR 30.09.11.03B; Noninvasive blood pressure monitor; Invasive blood pressure monitor; End tidal carbon dioxide monitor with waveform display/recorder capable of providing quantitative reading; and Oxygen saturation monitor; Miscellaneous supplies and equipment: When transporting adult patients: One surgical and one needle crichthryotomy kit with transtracheal catheter ventilation system; Replacement tracheostomy tubes, one of each size 6 and 8 millimeters; One pleurevac; One electronic thermometer; and Two surgical clamps capable of clamping up to a 40 french chest tube; When transporting pediatric patients: One surgical and one needle crichthryotomy kit with transtracheal catheter ventilation system; Replacement tracheostomy tubes one each size 1, 2, 3, and 4 millimeters, and age-appropriate size during transport; One pleurevac; One electronic thermometer; and Two surgical clamps; and Medications including: All ALS medications listed in the Maryland Medical Protocols for Emergency Medical Service Providers; and Additional medications approved for use by the specialty care service medical director to meet the needs of the types of patients being transported. A list of the additional medications used by the specialty care service shall be provided to SOCALR and shall be available on each ambulance when in use for a specialty care transport. SOCALR shall be notified in writing of any changes to the list of additional medications used by the specialty care transport service, other than a temporary change resulting from a medication shortage, within 7 days of the change. There shall be sufficient quantities of medications to care for one patient for the longer of: 1 hour; or Two times the estimated time of transport. If the ambulance is also licensed as a neonatal ambulance under COMAR 30.09.12, the vehicle does not need to carry duplicates of required items. Education Article, §13-515, Annotated Code of Maryland Effective date: January 15, 2005 (32:1 Md. R. 1866) Regulation .02G—I amended effective September 1, 2014 (41:17 Md. R. 971) Regulation .04 amended effective May 27, 2024 (51:10 Md. R. 529) Regulation .04B, C amended effective December 12, 2013 (40:24 Md. R. 2017); September 1, 2014 (41:17 Md. R. 971); October 16, 2023 (50:20 Md. R. 889) Regulation .04D adopted effective September 1, 2014 (41:17 Md. R. 971) Regulation .05 amended effective December 12, 2013 (40:24 Md. R. 2017) Regulation .05C amended effective September 1, 2014 (41:17 Md. R. 971) Regulation .07 amended effective September 1, 2014 (41:17 Md. R. 971)