Trauma Care System Plan Requirements and Determination Process.

22 CCR 100139.03

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23 segments

22 CCR 100139.03

§ 100139.03. Trauma Care System Plan Requirements and Determination Process.

(a)

Plan Submission to EMSA. Prior to the implementation of a new trauma care system, the local EMS agency (LEMSA) shall complete the Initial Trauma Care System Plan Template (Rev. 11/2025), incorporated by reference, and submit to the Emergency Medical Services Authority (EMSA) for approval, as set forth below.

(b)

Determination and Notification Process. Following the submission of a trauma care system plan, EMSA shall review the plan for completeness and compliance with the requirements of Division 2.5 of the Health and Safety Code, this subchapter, and the Initial Trauma Care System Plan Template (Rev. 11/2025), incorporated by reference. EMSA shall:

(1)

Acknowledgement. Within thirty (30) days of receiving the plan submission, provide written notification to the LEMSA to acknowledge receipt of the trauma care system plan and state whether the trauma care system plan is:

(A)

Complete, meaning it contains all information required by the Initial Trauma Care System Plan Template (Rev. 11/2025), or

(B)

Incomplete. If the trauma care system plan is incomplete, EMSA's notification shall identify the deficiencies.

(2)

Determination. Within sixty (60) days of receiving the trauma care system plan, EMSA shall provide written notification to the LEMSA that the plan is:

(A)

Approved, or

(B)

Denied. If the plan is denied, the notice shall specify the reasons for denial, including identification of the plan's failure to meet applicable statutory or regulatory requirements.

(c)

LEMSA Response to a Denial. If EMSA denies a trauma care system plan, the LEMSA shall have six (6) months from the date of the notification of the denial to:

(1)

Submit a revised trauma care system plan which conforms to the requirements of Division 2.5 of the Health and Safety Code and this subchapter, or

(2)

Appeal the decision pursuant to Section 1797.105 of the Health and Safety Code. A proceeding before the Commission on EMS (the Commission) to hear an appeal of a trauma care system plan denial shall be conducted in accordance with the provisions of Section 100000.01 of this Division.

(d)

Implementation of an Approved Plan. If a trauma care system plan is approved by EMSA or following a successful appeal to the Commission, the LEMSA shall begin implementation of the trauma care system plan within six (6) months of the date of the plan approval.

(e)

Rescinding Approval. A LEMSA's failure to implement its trauma care system in accordance with the approved trauma care system plan may result in EMSA rescinding approval of the trauma care system plan.

(1)

For purposes of this section, “failure to implement” means a failure to execute the trauma care system plan in a manner consistent with the approved plan, including deviations that affect the structure, function, or effectiveness of the trauma care system. In determining whether a failure to implement has occurred, EMSA shall consider factors including but not limited to:

(A)

The extent to which the trauma care system deviates from the approved plan;

(B)

The impact of the deviation on patient care, system operations, or access to care;

(C)

The duration and frequency of the deviation; and

(D)

Whether the LEMSA has taken corrective action to address identified deficiencies.

(2)

EMSA will consider any information, including but not limited to that received in connection with a subsequent trauma system status report, site visits, complaints, or pending litigation indicating that the LEMSA has failed to implement the trauma care system in accordance with the approved trauma care system plan. If EMSA determines that the trauma care system has not been implemented in accordance with the approved plan, EMSA may rescind approval of the trauma care system plan following written notice to the LEMSA. Any rescission shall be subject to a right of appeal in accordance with Section 1797.105 of the Health and Safety Code and the provisions of Section 100000.01 of this Division.

(f)

Trauma System Status Report Ongoing Review. As part of its annual EMS plan update the LEMSA shall include a trauma system status report, as set forth in Section 100139.04 of this article.

(g)

Plan Modifications. The LEMSA shall submit any significant changes to the trauma care system to EMSA for approval, prior to implementation of the change(s), utilizing the Annual Trauma System Status Report Template (Rev 11/2025), incorporated by reference. Significant changes include, but are not limited to, closures of general acute care hospital trauma services, changes to adult or pediatric trauma center American College of Surgeons verification level, and changes to critical LEMSA trauma destination policies. In instances where a delay in approval would adversely impact the current level of trauma care, the LEMSA may implement the changes after electronic notification to EMSA. Within thirty (30) days of implementation, the LEMSA shall submit an amended Annual Trauma System Status Report Template reflecting all changes to EMSA for approval.

(h)

Public Notice Requirement. The LEMSA shall share the approved trauma care system plan on their website as part of its approved local EMS plan.

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