Ground Ambulance Licensing - Mandatory Incident Reporting FAQs

Q: What types of incidents must be reported to the department immediately?

A: Ground ambulance services must report the following incidents within seven (7) days of discovery:

• Final actions or determinations by any state or federal government agency related to substandard care, healthcare fraud, or DEA license issues
• Civil judgments or criminal convictions involving operation, management, or ownership related to substandard patient care, healthcare fraud, or moral turpitude
• Termination or suspension from employment of an EMS provider for any reason listed in 6 CCR 1015-3, Chapter One, Section 7. Suspension or revocation of a medical director’s physician license
• Unexpected or untimely separation of a medical director

Q: What types of incidents are required to be reported within 90 days?

A: The following incidents must be reported to the department within 90 days of discovery by the licensed ground ambulance service:

• Physical or sexual assault by an ambulance service member
• Patient abuse or neglect
• Unauthorized possession of medications, supplies, or personal items
• Impaired service provision due to alcohol or drugs
• Care provided by someone impersonating a healthcare provider
• Death or injury from a motor vehicle collision involving an ambulance
• Administration of adulterated or contaminated drugs, devices, or biologics
• The following incidents that lead to injury, illness, or death to a patient not ordinarily expected as a result of the patient’s condition:

• Medication error or medical act error
• Invasive procedure performed on the wrong site
• Use or function of a device in a manner other than as intended or approved by medical direction
• Use of physical or chemical restraints
• Patient suicide or attempted suicide that occurs during the provision of care

Q: A reportable incident occurred at our agency last month, and we are still working through our quality assurance review. This won’t be completed within the required 90-day reporting period. Can an ambulance service request an extension for the reporting deadline? If so, how do we go about requesting an extension?

A: Yes, ground ambulance services may request an extension to the 90-day reporting deadline if additional time is needed to complete the quality assurance process. The department may grant extensions up to but not exceeding a total of 90 days. To request an extension, email cdphe_groundambulance@state.co.us.

Q: We had a “90-day” incident occur at our agency and have completed our quality assurance review. What information do we need to provide in the mandatory incident report?

A: Once your agency has determined through its quality assurance program that a reportable incident has occurred, you have 90 days following discovery of the incident to submit a report to the department that:

• Describes the incident review; and
• Identifies whether additional corrective measures are necessary to prevent reoccurrence of the reported incident; and
• Specify each corrective measure that will be undertaken to prevent the reoccurrence of the reported incident.

Q: Our ambulance service has a mandatory incident report ready to submit to the department. How do we submit the report to the department?

A: The mandatory incident report can be found in your OATH account under applications starting July 1, 2024. Only the account gatekeeper, ground ambulance administrator, or medical director can access the form.

Steps to access the Mandatory Incident Reporting Form:

1. Log in to your OATH account.
2. Click ‘Applications’ on the left menu.
3. Click ‘View Services Applications’ next to the name of the service for which you are submitting a mandatory incident report.
4. Click the ‘Apply Now’ button next to the “Ground Ambulance - Mandatory Incident Report form”*.
5. Complete the 1-page report form and submit it for review.
6. You will be required to upload documentation via a file attachment on the report form.

*Note: you can submit multiple Mandatory Incident Reports by repeating the steps above, as needed.

For questions regarding ground ambulance licensing, please email cdphe_groundambulance@state.co.us or call 303-691-4932.