Auditor General Report 02/04/1983 BOARD OF DIRECTORS
PAUL W.MILELLI
Florida Pre„dent
MIKE RUDD TERRY DILLON
Association Vice-President Secretary/Treasurer
County JOAN PYLE CHARLES FUTCH
Emergency EX-OFFICIO
Medical JAMES ALGOOO KURT SPITZER
Past President Gws strr ei
Services, Inc. S.A.C.C.
l
ALACHUA
BREVARO
BROWARD
CHARLOTTE February 4, 1983
CITRUS
CLAY
COLLIER
HARDEE
ENDRY TO: All FACEMS Members
HIGHLANDS , L/
HOLMESROUGH FROM: Paul W. Milelli, President
LEE
LEVY RE: AUDITOR GENERAL REPORT
MANATEE
MARTIN
MONROE
NASSAU Enclosed you will find the "position paper” of the EMS
ORANGE Providers Association. You will also find the sections
osceou of the Auditor General's Report dealing with EMS. Please
PALM BEACH
PASCO read this report and be ready to discuss it at our next
PINELLAS meeting.
POLK
SARA
OT Our next meeting will be attended by both Larry Jordan,
UNION EMS Administrator and Dr. Stephen King, State Health Officer.
VOLUSIA Your attendance and input is needed.
PLUM:emk
Enclosures
P. 0. Box 6926 • Ft. Myers, Florida 33911-0113 • (813) 335-2488
PROPOSAL OF THE EXECUTIVE BOARD OF EMS PROVIDERS
It is the recommendation of the EMS Providers Association that the
Department of HRS retain full and total control of programming,
certification, licensure, planning, and all other aspects of the
EMS System of the State of Florida.
These proposals are being made to assist with the following in order
to:
1. Maintain the integrity of EMS as a profession.
2. Save taxpayer funds.
3. Protect consumer costs.
4 . Have an impartial agency deal with EMS.
5. Prevent fragmentation into two agencies which would result
in further buerocratic complications resulting in decreased
service to the public.
It is further recommended that the following proposals be implemented:
1. The process of automating the licensure and certification program
be accomplished expeditiously and be retained in DHRS.
2. The EMS Office be upgraded to a higher level to that of a
Division or Bureau which may consist of other emergency preventative
programs .
3. Increasing EMS professional staff and upgrade the requirement
for appointment in order to secure well trained, knowledgeable,
professionals in prehospital emergency care.
4. The implementation of an advisory board to provide expertise and
direction to the office of EMS from the professional providers
of prehospital care.
5. The development of an equitable fee structure for all EMS providers
to provide adequate funding for the above proposals.
6 . To allow continuance of frequent state testing for certification
of Emergency Medical Technicians and Paramedics. We feel this
is necessary to prevent the loss of many well qualified persons
who cannot afford to wait three to six months to begin their
professional careers.
IV FINDINGS AND RECOMMENDATIONS
Section 1: Emergency Medical Services Personnel Licensing Program
Background: Licensing Practices
The goal of regulating emergency medical services personnel
is to protect the health and welfare of the public by requiring
emergency medical technicians and paramedics to demonstrate
proficiency in the treatment of life-threatening emergencies. Chapter
401, Part III, Florida Statutes, provides standards for licensing
emergency medical technicians and paramedics, establishes license
fees, and provides penalties for violating licensing laws.
The emergency medical services personnel licensing program
comprises the following functions:
o Developing and administering examinations
o -Processing license applications
o Investigating complaints against licensees
o Approving training programs and continuing education
courses.
To be licensed as an emergency medical technician or
paramedic, an applicant must meet State educational, experience, and
personal background qualifications as well as successfully pass a
State licensing examination.
Prior to October 1, 1982, the Office of Emergency Medical = -
Services administered emergency medical technician license
examinations at nine locations three times per year and paramedic
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used in September 1977 to test approximately 700 people. The source •
and authors of this test were unknown.
The Office has contracted with Associated Consultants in
Education since 1977 to provide examination analysis services at a
current fiscal year cost of $4,200. We found numerous complaints over
this period from training program instructors, Department of Education
officials, and emergency medical service personnel regarding
examination questions and test development procedures. These have
included:
o The use of poorly designed examination questions
o The confusing use of trial questions within the licensing
examinations
o The use of questions derived from sources that provide
contradictory information on proper emergency medical
care.
Office of Emergency Medical Services' officials told us they
tried to resolve the problems with licensing examinations by entering
into a contract with a testing firm, Professional Examination Service,
in December 1980 to develop emergency medical technician and paramedic
test questions and examinations at a total cost of $21, 787. The
Office finally received the test questions in August 1982, but never
•
received any developed licensing examinations.
In conjunction with and in addition to this contract, the
Office contracted with Associated Consultants in Education to perform
validity analyses on new and existing questions, and to aid in the
y `
development of new comparable examinations. Associated Consultants in
Education was only able to complete validation procedures for the
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The Office of Emergency Medical Services has been deficient
in investigating complaints made against emergency medical service
personnel. A review of Office activity reports identified several
cases where Office staff claimed that emergency medical service
providers were using unlicensed personnel. However, no records of
further investigations of these violations could be found in the
complaint files. We were also told by emergency medical services
providers that complaints they sent to the Office were never
investigated. The Office did not maintain separate records of
complaints received and actions taken until January 1982.
The lack of effectiveness in investigating complaints may
result from the Office' s interpretation of its mission. For example,
we interviewed Office officials who stated that their objective is to
provide technical expertise and assistance, rather than to police
licensed professionals. Several Office officials said that they take
a conciliatory approach toward violators of licensing laws and
regulations.
We recommend that the Legislature transfer authority to
license emergency medical services personnel to the Department of
Professional Regulation. There are several reasons why this transfer
should improve the effectiveness and efficiency of the licensing
process. First, the Department of Professional Regulation has a full-
time staff of examination specialists and has standard procedures for
evaluating the validity of examinations. Second, the Department has
an automated license processing system that enables it to process ~ `
applications, schedule examinations, issue licenses, and record
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We further recommend that the Legislature amend the law to
eliminate the present requirement that licensing examinations be
administered within 10 days of training program completion. This
requirement may increase the number of times examinations are
administered from 45 times per year to approximately 104 times per
year, causing an increase in administration and examination scoring
costs, and making it more difficult to ensure the security of
examinations. Other health professions regulated by the Department of
Health and Rehabilitative Services and by the Department of
Professional Regulation do not have similar deadlines for
administering tests or similar numbers of tests per year.
Exhibit 1 presents. the Department of Health and
Rehabilitative Services' reported expenditures for licensing emergency
medical services personnel in fiscal year 1981-82, as well as the
Department of Professional Regulation' s estimate of what it would have
cost that agency to carry out the function. The Exhibit also presents
license statistics and current and projected license fees.
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is
TABLE V-2
CURRENT AND ESTIMATED FEES FOR ALLIED HEALTH PROFESSIONALS
Department of Health and Rehabilitative Services Department of Professional Roguish(
Current Fees Estimated Fees
A Ifeatfon Examination enew Llcsnsi R
n Examination Licensing- Renewal
Emergency Medical Services:
Emergency Medical Technicians 15 20 10 (Triennial) 33 :
Paramedics
15 55 55 2$ 28
(Triennial) 33 + ZB 28
Clinical Laboratory Personnel:
Director
Supervisor 30 (Annual) 41 25 25
Technologist 15 , 20 (Annual) 41 25 25
Technician 10 ' 15 (Annual) 41 25 25
Trainee 2 10 (Annual) 41 25 25
2
Lay Midwife
100 Al 100 '(Biennial) 2,157
Hearing Aid Dispensers: 1' 153
Dispenser
Trainee 25 50 75 75 (Annual) 150 158
158
Radiologic Technologist 25 ,
20 (Biennial) 42 28 28
' Renewal lees based on annual renewal.
1 ' The data originally supplied to the Department of Professional R
examination fees would be reduced to$30. Regulation was in error.After correcting this error,we estimate
! The application fee includes fees for examination and licensing.An additional fee of>S is required for each s
taken. g.
Maximum fee specified in Chapter 487, Florida Statutes,is$100: fees have not specialty examination
' The application fee includes fees for examination and licensing. yet set by rule.
Source: Florida Statutes, Florida Administrative Code, and estimates provided by the Department of Professional Regulation.
TABLE V-3
REPORTED LICENSE STATISTICS FOR ALLIED HEALTH PROFESSIONALS
FISCAL YEAR 1981-82
Emergency Clinical Lay Medical Laboratory Midwives Hearing Radiologic
Aid Technologists
Services Personnel
Personnel Dispensers
Licensees 27,500 14,823 30 502 7,295
Licenses Issued
Renewals Issued 4,006 2 2,243
3,224 14,823 8 ' '
Number Examined 4,870 22 ' 936
2,822 8 206
1,499
Includes 4,500 ambulance drivers who are no longer licensed by the State.
' Includes 780 ambulance drivers who are no longer licensed by the State.
Not reported.
Source: Department of Health and Administrative Services offices responsible for operating personnel licensing programs,. `
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1
VI RESPONSE FROM THE DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
STATE OF FLORIDA
DEPARTMENT OF Bob Graham.Governor
Health & Rehabilitative Services �`
1317 WINEWOOD BOULEVARD TALLAHASSEE, FLORIDA 32301
January 4, 1983
Mr. Ernest Ellison
Auditor General
Post Office Box 1735
Tallahassee, Florida 32301
Dear Mr. Ellison:
Attached are my general comments to the preliminary and
tentative adverse audit findings which may be included in a
report of the Performance Audit of State Licensina of Allied
Health Professionals by the Department of Health and
Rehabilitative Services. Individual responses to each section
included in the FINDINGS AND RECOMMENDATIONS portion of your
preliminary report follow my general comments.
The Department concurs that the overall objective of the
State of Florida is to develop the most economical, effective,
and efficiently coordinated structure for administering allied
health profession licensing procirams . As you point out in your
preliminary report, the licensing of health professions is
intended to accomplish several objectives, including: providing
greater quality of care; limiting personal exposure to risk; •
controlling abuse; and ensuring the competence of practitioners.
The Department suggests that the transfer of responsibility for
licensing allied health professionals to the Department of
Professional Reaulation (DPR) may not be in the best interest of
these oronrams.
This suggestion is based in part on the following factors.
Your Preliminary report indicates that the licensing function
would he less economical under DPR than HRS and, given current
economic conditions, transfer of programs may not be feasihle.
Auditor Cenerel report numher 10132, dated December 1, 1982, on
DPP indicated that the Department had made significant
improvements in the major areas of licensing and enforcement but
that further improvements and controls were needed. . Overall r
effectiveness and efficiency of DPR could be hindered if the
iicensinn of allied health professionals is transferred before
DPP can implement the needed improvements.
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Mr. Ernest Ellison
Page Two
We support the recommendation that the Legislature transfer
responsibility for licensing Emergency Medical Services
personnel to DPR. However, we do not recommend transfer of the
other allied health services at this time. As shown in the
attached response, there are many significant efforts currently
underway to improve these services in HRS. Also, major
legislative activity is anticipated by the 1983 Legislature due
to Sunset provisions.
I and HRS staff welcome the opp'rtunity for further
discussion of these areas. Your staff have been most
cooperative while conducting the performance audit. I assure
you that the Department shares your interest and concern in
providing the most economical, efficient and effective services
to citizens of the State of Florida.
Sincerely,
w
David H. Pingree
Secretary
Attachment
•
•
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Section 1 : Emergency Medical Services Personnel Licensing
(Audit Report Program
Page 17)
General Response: The placement of the function of certifying
(From }IRS) professionals such as emergency medical
technicians (EMTs ) and paramedics in an
organization which is solely dedicated to this
type of activity should offer the potential for
efficiencies and cost savings, particularly in
the areas of examination administration and
incompetency investigations. HRS also agrees
that the separation of the currently integrated
EMS personnel certification and EMS provider
licensing functions will offset some of the
potential efficiency in the former area. HRS
does believe, however, that the facts justify
that HRS is administering the EMS personnel
certification program in an efficient and
effective manner.
Prior to 1973, Florida was generally
under-served or completely without qualified
pre-hospital emergency medical services
personnel., vehicles, and equipment. In the
relatively short period since the enactment of
the first EMS Law in 1973 (which was • amended to
include paramedics and advanced life support
services only as late as 1979) , Florida has
progressed to the point where, today, there are
191 basic life support services and 132
advanced life support services which utilize
over 1,400 permitted vehicles. These provide
100 percent statewide coverage with basic life
support services and 80 percent statewide
coverage with advanced life support services.
In addition, the EMS Office has overseen the
trainina, examination and certification of
18, 000 emergency medical technicians and 3, 000
paramedics.
The followina are responses to specific
findinos and recommendations contained in the
Preliminary report:
Finding: The Department of HRS has not administered the
(Audit Report EMS personnel licensing program in an efficient
Page 18) and effective manner.
Response: The preliminary report accurately reflects
(From HRS) early problems with EMT examinations , but fails --
to point out that, from a national as well as
•
state perspective, the entire field was in its
infancy in 1973 when Florida' s first EMS
statute was enacted. This means there were no
-60-
•
Response: HRS does not have an automated licensing
(From HRS) processing and record keeping system, and
concurs that growth of EMS in Florida has
outstripped a manual system of record keeping.
We also acknowledge that changes in circum-
stances resulted in a management decision to
shift from a system designed by a data
processing consultant to one which utilizes the
Florida Licensing Information System (DPR
System) . The EMS Office has completed
loading of the paramedic data file, and EMT
file loading should be completed within the
next two weeks; i.e. these two major work load
obstacles necessary for implementation of the
DRP system are virtually finished. Therefore,
the Department concurs with the recommendation
to transfer the EMS personnel licensing
function to DPR.
Finding: The Office of Emergency Medical Services has
(Audit Report been deficient in investigating complaints made
Page 21) against emergency medical services
personnel.
Response: A review of the EMS Law reveals that
prior HRS) October 1, 1982 ( the effective date of the rnew
EMS Law) , HRS had no authority to judge the.
operational competency of EMS personnel nor
penalties available in cases of incompetency.
Further, the only sanctions available to HRS in
cases of noncompliance by EMS services or
substandard vehicles , were- revocation or
suspension of their licenses and permits.
Revocation was difficult to use when dealing
with the only service available to a community.
Therefore, the Department was forced to use
persuasion and public opinion in order to
effect corrective action. Despite the lack of
effective sanctions, the EMS Office did
investigate complaints against EMS services and
conduct follow-up inspections for correction of
deficiencies discovered during its licensure
inspections. It is acknowledged that a system
for formal documentation of complaints and
their resolution was not implemented until
early 1982. In recognition of the foregoing
problems, HRS, during the 1982 Sunset Review of
the EMS Law, recommended to the Legislature
that the new law contain provisions for judging
competency and disciplining incompetent EMS
personnel and to sanction, by administrative y -
fine, persons out of compliance with EMS Law _
and Rules. These recommendations were
supported by the Legislature and are now
incorporated in the new law.
-62-
Response: Table V-1, which presents reported and
(From HRS) estimated program costs, reflects that the
estimated cost of the DPR system would be
$485,822 annually while the cost of the HRS
program is reported as $451,156 annually. —�
However, according to this table, approximately
$235,751 of HRS costs relate to programs which
are not recommended for transfer to DPR
( 5211,191 for service licensing and inspection
and approximately 53 percent of Other and
Administrative Overhead costs, or $24, 560) .
Therefore, the comparable figures are $485,822
for the DPR program and 3215, 405 for the DERS
program. This more than two-fold increase
appears to support the representation that
transferring the licensing program to DPR will
not be more economical than the current
licensing program. In addition, it should be
pointed out that EMS does not have a current
contract with a testing service to develop new
examination questions. This information would
seem to indicate that, in order to produce the
revenue required by DPR, fees would have to be
increased significantly above the current legal
maximum just established by the 1982 EMS Law.
This would, of course, require legislative
approval. We believe that a more comprehensive
cost evaluation is required in order to
determine the precise effect on fees resulting
from the proposed transfer.
Auditor General's In Exhibit 1 of this report (see pages 52-54), we pointed
Remarks Relative out that the Department of Professional Regulation may have
to HRS Response: overstated estimated costs. We also believe that our
recommended use of an advisory council would avoid the
additional administrative and staffing costs associated with
licensing boards.
More specifically, the Department of Professional Regulation
estimated costs based upon receiving 375 complaints during
the fiscal year. However, during the first six months of
1982 the Office of Emergency Medical Services had received
only 17 complaints. Assuming all these complaints dealt
with personnel, the annualized number is well under the
Department of Professional Regulation's estimate. Even with
an increased amount of complaint investigation activity
through stronger enforcement, we believe the Department of
Professional Regulation's estimated costs may be overstated
by as much as $150,000 (including complaint analysis,
investigation, and legal services).
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l
MEMO TO: EMSAC MEMBERS
FROM: W . Neil Dorrill , Public Safety Administrator
DATE : February 3 , 1983
SUBJECT : NOTICE OF FEBRUARY REGULAR MEETING
Be advised that the next regular meeting of the Emergency
Medical Services Advisory Council will be held on
THURSDAY , February 10 , 1983
5th Floor Conference Room - 250 4 :00 PM
If for any reason you will be unable to attend , please notify
my office (774-8468) or Chairman Hill (261 -0569 ) so that your
absence will be considered as excused . REMEMBER : According
to Article V , Section 5 , Paragraph C , any member having missed
two ( 2 ) unexcused consecutive or three (3 ) unexcused total
Council meetings within one year will be reported to the
Executive Committee .
A REMINDER : The meeting day for the EMSAC has been changed
from the second Tuesday of the month to the second THURSDAY
of the month .
WND/bm
Attachment : AGENDA
AGENDA
EMERGENCY MEDICAL SERVICES ADVISORY COUNCIL
Meeting of February 10 , 1983
I . Roll Call
II . Reading and/or approval of minutes
a) Regular meeting of January 11 , 1983
III . Advisors Reports
IV . Old Business
V . New Business
VI . Adjourn
/bm
0
MEMO TO: EMSAC MEMBERS - Moot o," C'ec dt
FROM: W. Neil Dorrill/Public Safety Administrator
DATE: February 25 , 1983
SUBJECT: Minutes of Meeting
In accompaniment please find copy of the Minutes of
the regular meeting held on February 10 , 1983 . Please review
these in order that they can be adopted at the next meeting
to be held on Wednesday, March 9, 1983 at 4 :00 PM in the
5th Floor Conference Room.
Please note that the meeting day for the EMSAC has again
been changed from the second Thursday of the month to the
second WEDNESDAY of the month.
WND/bm
cc : C. William Norman, County Manager
File 14-D