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)