Ga. Comp. R. & Regs. R. 511-9-2-.07 - Licensure of Ground Ambulance Services

(1) Applicability.

(a) No person shall operate, advertise, or hold themselves out to be a Ground Ambulance Service in the state of Georgia without being in compliance with the provisions of O.C.G.A. Chapter 31-11 and these rules and regulations and without being duly licensed by the Department. However, this Rule shall not apply to the following:

1. An ambulance or ambulance service operated by an agency of the United States government;

2. A vehicle rendering assistance temporarily in the case of a major catastrophe, disaster, or public health emergency which is beyond the capabilities of available Georgia licensed ambulance services;

3. An ambulance operated from a location outside of Georgia and transporting patients picked up beyond the limits of Georgia to locations within Georgia;

4. An invalid car or the operator thereof.

5. An ambulance service licensed to operate in another state and transporting patients picked up at a medical facility within the limits of Georgia to locations outside the limits of Georgia unless such ambulance is pre-positioned within the limits of Georgia prior to receiving the request for transport.

6. An ambulance service licensed in another state, that is located in an adjacent county to the public call and is responding to a mutual aid request from a Georgia licensed ambulance service who is the Emergency Response Zone provider.

(b) No provision of these rules shall be construed as prohibiting or preventing a municipality from fixing, charging, assessing or collecting any license fee or registration fee on any business or profession or anyone engaged in any related profession governed by the provisions of these rules, or from establishing additional regulations regarding Ground Ambulance Services as long as there is no conflict with these rules.

(2) Application for a license or provisional license shall be made in the manner and on the forms specified by the Department, to include at a minimum the name, address, email address, and employer identification number of the owner(s).

(3) Renewal of License. Renewal of any license issued under the provisions of O.C.G.A. Chapter 31-11 shall require conformance with all the requirements of these rules and regulations as upon original licensing.

(a) Any license not renewed prior to the license expiration date is considered "Lapsed-Failure to Renew" and is not permitted to operate as a Ground Ambulance Service. Late renewal is permitted during the three (3)-month period immediately following the expiration date for the last license renewal cycle. After that three-month period, the agency must apply as a new applicant in accordance with applicable rules and regulations.

(4) Standards for Ground Ambulances.

(a) General.

1. Ground Ambulances must be maintained on suitable premises that meet the Department's specifications. The Department is authorized to establish policy to define minimal standards for suitable premises and Base of Operations. Ground Ambulances, including raised roof van or modular type, must meet design and safety standards as approved by the Department. The interior of the patient compartment shall provide a minimum volume of 30 cubic feet of enclosed and shelf storage space that shall be conveniently located for medical supplies, devices, and installed systems as applicable for the service intended. The Ground Ambulance must be properly equipped, maintained, and operated in accordance with other rules and regulations contained herein and be maintained and operated so as to contribute to the general well-being of patients. Heat and air conditioning must be available and operational in both the patient compartment and driver compartment.

2. All Ground Ambulances must be equipped with approved safety belts for all seats.

3. Prior to their use, Ground Ambulances must be inspected and approved by the Department and so registered by affixing a Department decal at a location specified by the Department. Any Ground Ambulance manufactured or remounted on or after July 1, 2027 must meet the current Commission on Accreditation of Ambulance Services (CAAS) Ground Vehicle Standards or National Fire Protection Association (NFPA) Standard for Automotive Ambulances.

4. Each Ground Ambulance Service may place up to one-third (rounded to nearest whole number) of its registered Ground Ambulances in reserve status. When a Reserve Ambulance is placed in service (ready to respond to an emergency call) it must meet the provisions of these rules and policies of the Department.

5. Prior to disposal by sale or otherwise, a Ground Ambulance removed from service must be reported to the Department.

6. All registered Ground Ambulances shall have on both sides of the vehicle an identification number designated by the Department. The name of the Ground Ambulance Service and the vehicle identification number shall be visible on each side of the Ground Ambulance in at least 3-inch lettering for proper identification.

(b) Insurance:

1. Each registered Ground Ambulance shall have at least $1,000,000 combined single limit (CSL) insurance coverage.

2. No Ground Ambulance shall be registered nor shall any registration be renewed unless the Ground Ambulance has insurance coverage in force as required by this section. A certificate of insurance or satisfactory evidence of self-insurance shall be submitted to the license officer for approval prior to the issuance or renewal of each Ground Ambulance license. Satisfactory evidence that such insurance is at all times in force and effect shall be furnished to the Department in a manner and on forms specified by the Department, by all licensees required to provide proof of such insurance under this section. Any lapse in insurance coverage will be grounds for immediate revocation of the Ground Ambulance Service license.

3. Ground Ambulance Services must maintain a file, as defined in departmental policy, of all maintenance records on each vehicle registered by the Department.

4. The Ground Ambulance Service shall list the Georgia Office of EMS and Trauma as an additional certificate holder for the vehicle insurance with the insurance company.

(c) Fees:

1. Any fee submitted to the Department that results in insufficient funds will be assessed a non-sufficient fund fee. The return check fee and non-sufficient fee will be due within two business days by cashier's check.

(d) Communication:

1. Each registered Ground Ambulance shall be equipped with a two-way communication system that provides ambulance-to-hospital communications.

2. All Ground Ambulance Services shall have two-way communication between each Ground Ambulance and the location receiving requests for emergency service.

(e) Infectious Disease Exposure Control:

1. Each Ground Ambulance Service shall have a written infectious disease exposure control plan approved by the local Medical Director.

2. Ground Ambulance Services and Emergency Medical Services Personnel shall comply with all applicable local, state, and federal laws and regulations in regard to infectious disease control procedures.

(f) Equipment and Supplies:

1. All equipment and supplies must be maintained in working order and shall be stored in an orderly manner so as to protect the patient and be readily accessible when needed.

2. No supplies may be used after their expiration date.

3. In order to substitute any item for the required items, written approval must be obtained from the Department. The Department shall have authority to grant exceptions and substitutions and shall maintain and distribute an up-to-date policy listing of all approved exceptions and substitutions.

4. The Department shall establish through policy the minimum equipment and supplies required on each Ground Ambulance; however, other equipment and supplies may be added as desired.

(5) General Provisions for Ground Ambulance Services.

(a) No person shall make use of the word "ambulance" to describe any ground transportation or facility or service associated therewith which such person provides, or to otherwise hold oneself out to be an ambulance service unless such person has a valid license issued pursuant to the provisions of this chapter or is exempt from licensing under this chapter.

(b) Each Ground Ambulance while transporting a patient shall be manned by not less than two Medics, one of whom must be in the patient compartment. If Advanced Life Support is being rendered, personnel qualified to administer the appropriate level of Advanced Life Support must be in the patient compartment and responsible for patient care.

1. A Ground Ambulance may not be staffed by more than one (1) Emergency Medical Technician Responder, unless:

(i) Conducting an interfacility transfer; and

(ii) One (1) of the Emergency Medical Technician-Responders maintains an active, unrestricted Georgia license as a Registered Nurse, Nurse Practitioner, Physician Assistant or Physician.

2. Emergency Medical Technician - Responders may not staff Ground Ambulances that routinely respond to Public Calls, unless:

(i) The Emergency Medical Technician - Responder is also licensed as a registered nurse, nurse practitioner, physician assistant or physician with an unrestricted license; OR

(ii) The Ground Ambulance Service provides all of the following on an annual basis to the Department in a manner and on forms specified by the Department:

(I) An attestation that the staffing at the EMS Agency is currently insufficient to properly staff Ground Ambulances responding to Public Calls;

(II) An attestation that the public welfare may be negatively affected if the Ground Ambulance Service is unable to use the Emergency Medical Technician - Responder license level to staff Ground Ambulances that respond to Public Calls; and

(III) An attestation from the Ground Ambulance Medical Director that they fully support the use of Emergency Medical Technician - Responders on Ground Ambulances that respond to Public Calls for the Ground Ambulance Service.

3. Emergency Medical Technician - Responders who do not hold an additional Georgia license as a registered nurse, nurse practitioner, physician assistant or physician may not serve as the primary patient caregiver during patient transport on a Ground Ambulance.

(c) If a Medic possesses an additional Georgia healthcare provider license, then the Medic may perform to the higher level of training for which he or she is qualified under that license when directed to do so by a physician, either directly or by approved protocols.

(d) Interhospital transfers shall be conducted by licensed ambulance services in registered ambulances when the patient requires, or is likely to require, medical attention during transport. The transferring or receiving physician may request the highest level of Emergency Medical Services Personnel available or additional qualified medical personnel access to the patient during the interhospital transfer. If requested, the ambulance service must allow the highest level medical personnel available to attend to the patient during the interhospital transfer.

(e) Ground Ambulance Services responsible for an emergency response zone by designation or service delivery agreement shall be provided on a twenty-four hour, seven day a week basis.

(f) Personnel shall be available at all times to receive emergency telephone calls and provide two-way communications.

(g) Sufficient licensed personnel shall be immediately available to respond with at least one Ground Ambulance. When the first Ground Ambulance is on a call, Ground Ambulance Services shall respond to each additional emergency call within their designated geographic territory as requested provided that Medics and a Ground Ambulance are available. If Medics and a Ground Ambulance are not available, the Ground Ambulance Service shall request mutual aid assistance. If mutual aid assistance is not available the Ground Ambulance Service shall respond with its next available Ground Ambulance.

(h) Medical Direction for Ground Ambulance Services.

1. To enhance the provision of emergency medical care, each Ground Ambulance Service shall have a Medical Director. The local Medical Director shall be a physician licensed to practice medicine in the state of Georgia, must complete Department required training, and must be approved by the Department. The local Medical Director must agree in writing to provide medical direction to that particular Ground Ambulance Service.

2. The local Medical Director shall serve as medical authority for the Ground Ambulance Service, serving as a liaison between the Ground Ambulance Service and the medical community, medical facilities and governmental entities.

3. It will be the responsibility of the local Medical Director to provide for medical direction and training for the ambulance service personnel in conformance with acceptable emergency medical practices and procedures.

4. Duties of the local Medical Director shall include but not be limited to the following:

(i) The approval of policies and procedures affecting patient care;

(ii) The formulation of medical protocols and communication protocols;

(iii) The formulation and evaluation of training objectives;

(iv) Performance evaluation;

(v) Continuous quality improvement of patient care; and

(vi) Development and implementation of policies and procedures for requesting air ambulance transport.

5. Each Ground Ambulance Service shall have a minimum set of clinical guidelines and/or protocols for the assessment, treatment and transportation of both adult and pediatric patients as specified by the Department.

6. All Emergency Medical Services Personnel shall comply with appropriate policies, protocols, requirements, and standards of the local Medical Director for that Ground Ambulance Service, provided that such policies and protocols are not in conflict with these Rules and Regulations, the Department-specified Scope of Practice, or other state statutes.

(i) Control of patient care at the scene of an emergency shall be the responsibility of the individual in attendance most appropriately trained and knowledgeable in providing prehospital emergency care and transportation. When a Medic arrives at the scene of a medical emergency, the Medic may act as an agent of a physician when a physician-patient relationship has been established.

1. For purposes of this section, a physician-patient relationship has been established when:

(i) A Medic utilizes medical control, either through direct on-line medical control or off-line medical control, by the use of medical protocols established by the local Medical Director; or

(ii) A physician is on the scene and demonstrates a willingness to assume responsibility for patient management or purports to be the patient's personal physician and the Medic takes reasonable steps to immediately verify the medical credentials of the physician.

2. Once a physician-patient relationship has been established, the Medic must follow the medical direction of that physician. In the event of a conflict between the medical direction given and the medical protocols established by the local Medical Director, the Medic should immediately contact their local Medical Director.

(j) All licensed Ground Ambulance Services must adhere to all Regional Ambulance Zoning Plans approved by the Department. Any Ground Ambulance that arrives at the scene of an emergency without having been designated as responsible by the Regional Ambulance Zoning Plan, shall provide the emergency medical care necessary to sustain and stabilize the patient until the arrival of the designated Ground Ambulance Service. A non-designated EMS Agency shall not transport a patient from the scene of a medical emergency except under the following conditions:

1. The designated Ground Ambulance is canceled by the appropriate dispatching authority with express approval of the designated Ground Ambulance Service; or

2. Medical control determines that the patient's condition is life-threatening or otherwise subject to rapid and significant deterioration and there is clear indication that, in view of the estimated time of arrival of the designated Ground Ambulance, the patient's condition warrants immediate transport. In the event the Medic is unable to contact medical control, the Medic will make this decision. The transporting Ground Ambulance Service shall file a copy of the Patient Care Report to the Department in compliance with these rules, to include an explanation of the circumstances and the need for the non-designated Ground Ambulance Service to transport the patient.

(k) Hospital Destination of Prehospital Patients.

1. When a patient requires initial transportation to a hospital, the patient shall be transported by the ambulance service to the hospital of his or her choice provided:

(i) The hospital chosen is capable of meeting the patient's immediate needs;

(ii) The hospital chosen is within a reasonable distance as determined by the Medic's assessment in collaboration with medical control so as to not further jeopardize the patient's health or compromise the ability of the EMS system to function in a normal manner;

(iii) The hospital chosen is within a usual and customary patient transport or referral area as determined by the local Medical Director; and

(iv) The patient does not, in the judgment of the Medical Director or an attending physician, lack sufficient understanding or capacity to make a responsible decision regarding the choice of hospital.

2. If the patient's choice of hospital is not appropriate or if the patient does not, cannot, or will not express a choice, the patient's destination will be determined by pre-established guidelines. If for any reason the pre-established guidelines are unclear or not applicable to the specific case, then medical control shall be consulted for a definitive decision.

3. If the patient continues to insist on being transported to the hospital he or she has chosen, and it is within a reasonable distance as determined by the local Medical Director, then the patient shall be transported to that hospital after notifying local medical control of the patient's decision. The choice of hospital for the patient may be selected pursuant to O.C.G.A. § 31-9-2.

4. If the patient does not, cannot, or will not express a choice of hospitals, the Ground Ambulance Service shall transport the patient to the nearest hospital believed capable of meeting the patient's immediate medical needs without regard to other factors, e.g., patient's ability to pay, hospital charges, county or city limits, etc.

(l) Ground Ambulance Services and applicants for Ground Ambulance Services shall not misrepresent or falsify any information, applications, forms or data filed with or submitted to the Department or completed as a result of any ambulance response.

(m) Ground Ambulance Services shall not utilize as Medics any individuals who are not properly licensed under the applicable provisions of O.C.G.A. Chapter 31-11 and these rules and regulations.

(6) CLIA Certification

(a) All Ground Ambulance Services must maintain current CLIA certification as a laboratory that is permitted to perform waived tests, as defined in 42 CFR § 493.2.

1. Documentation regarding this certification must be submitted to the Department in a manner and on forms specified by the Department.

Notes

Ga. Comp. R. & Regs. R. 511-9-2-.07

O.C.G.A. §§ 31-2A-3, 31-2A-6, 31-9-2, 31-9-3, 31-11-5 to 31-11-11, 31-11-30 to 31-11-36, 31-11-50 to 31-11-55, 31-11-60.1, 31-12-8, 40-6-6.

Original Rule entitled "Licensure of Ground Ambulance Services" adopted. F. December 14, 2011; eff. January 3, 2012. Amended: F. Apr. 27, 2016; eff. May 17, 2016. Amended: F. Apr. 24, 2018; eff. May 14, 2018. Amended: F. Sept. 29, 2021; eff. Oct. 27, 2021, as specified by the Agency. Amended: F. Feb. 17, 2025; eff. Mar. 16, 2025, as specified by the Agency.