BEFORE THE BOARD OF MEDICAL EXAMINERS

                                DEPARTMENT OF LABOR AND INDUSTRY

                                                  STATE OF MONTANA

 

In the matter of the amendment of ARM 24.156.2701 definitions, 24.156.2705 unprofessional conduct, 24.156.2707 reporting to the board, 24.156.2711 ECP licensure qualifications, 24.156.2713 ECP license application, 24.156.2715 substantially equivalent education, 24.156.2718 continuing education and refresher requirements, 24.156.2719 expired license, 24.156.2731 fees, 24.156.2732 medical direction, 24.156.2751 levels of ECP licensure including endorsements, 24.156.2752 ECP endorsement application, 24.156.2761 procedures for revision of Montana ECP practice guidelines or curriculum, 24.156.2771 ECP scope of practice; the adoption of New Rule I ECP training courses and New Rule II final pre-licensing examinations; and the repeal of 24.156.2708 complaints, 24.156.2717 ECP license renewal, 24.156.2741 ECP training program/course application and approval, 24.156.2745 examinations, 24.156.2754 initial ECP course requirements, 24.156.2755 post-course requirements, 24.156.2757 ECP clinical requirements

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT, ADOPTION, AND REPEAL

 

TO: All Concerned Persons

 

            1. On February 15, 2019, at 1:30 p.m., a public hearing will be held in the Basement Conference Room, 301 South Park Avenue, Helena, Montana, to consider the proposed amendment, adoption, and repeal of the above-stated rules.

 

            2. The Department of Labor and Industry (department) will make reasonable accommodations for persons with disabilities who wish to participate in this public hearing or need an alternative accessible format of this notice. If you require an accommodation, contact the Board of Medical Examiners no later than 5:00 p.m., on February 8, 2019, to advise us of the nature of the accommodation that you need. Please contact Ian Marquand, Board of Medical Examiners, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513; telephone (406) 841-2360; Montana Relay 1 (800) 253-4091; TDD (406) 444-2978; facsimile (406) 841-2305; or dlibsdmed@mt.gov (board's e-mail).

 

            3. GENERAL REASONABLE NECESSITY STATEMENT: In 2017, department staff who work exclusively with the board on subjects related to board-licensed emergency care providers (ECP) made a series of suggestions to the board for potential rule revisions.  Following extensive development by department staff, discussion within the board's laws and rules committee and medical direction committee, and consideration by the full board, the board determined it is reasonably necessary to amend several of the ECP rules to implement the recommended changes.  Where additional specific bases for a proposed action exist, the board will identify those reasons immediately following the specific rule.

 

            4. The rules proposed to be amended are as follows, stricken matter interlined, new matter underlined:

 

            24.156.2701 DEFINITIONS (1) For purposes of the rules set forth in this subchapter, the following definitions apply:

            (a) "ABPC" means the American Board of Prehospital Care, an organization that certifies EMS care providers.

            (a) "AEMT" means an individual licensed by the board at the level of advanced emergency medical technician.

            (b) "Advanced life support" or "ALS" means any provider that functions at any endorsement level above EMT.

            (c) "Approved course" means a course of initial instruction that meets the specifications and requirements for a particular level of ECP training approved by the board or its designee.

            (d) "Approved program" means a multiple of approved courses offered by an entity and approved by the board or its designee.

            (e) "Basic life support" or "BLS" means any provider that functions at the endorsement level of:

            (i) EMR;

            (ii) EMR with any endorsements; or

            (iii) EMT without any endorsements.

            (f) remains the same but is renumbered (b).

            (g) (c)  "Clinical experience" means supervised instruction, observation, or practice in a patient care setting as part of an approved course or program a curriculum.

            (h) (d)  "Clinical preceptor" means an individual trained licensed to a licensure level greater than the student, who is responsible for supervising and teaching the student in a clinical setting in an approved course or program, under the supervision of the medical director or lead instructor in the case of an EMT course.

            (i) (e)  "Curriculum" means the combination of the National EMS Educational Standards and the Instructor Guidelines prepared by the United States Department of Transportation (USDOT), and the Montana ECP Practice Guidelines, or substantially equivalent standards as determined by the board or its designee.

            (f) "ECP" means an emergency care provider as defined under 37-3-102, MCA.

            (g)  "EMR" means an individual licensed by the board at the level of emergency medical responder.

            (j) (h)  "Emergency medical service" or "EMS" means out of hospital care and transportation furnished by a combination of persons licensed by the board and resources that are an emergency medical service licensed by the Department of Public Health and Human Services pursuant to Title 50, chapter 6, MCA.

            (k) "Emergency medical technician" means any out-of-hospital emergency care provider or "ECP" licensed by the board.

            (l) (i) "Emergency medical technician" "EMT" means an individual licensed by the board as an EMT at the level of emergency medical technician.

            (m) "Emergency medical technician - emergency medical responder" means an individual licensed by the board as an EMR.

            (n) "Emergency medical technician - advanced emergency medical technician" means an individual licensed by the board as an AEMT.

            (o) "Emergency medical technician - paramedic" means an individual licensed by the board as a paramedic.

            (p) (j) "Endorsement" means a supplemental level of licensure issued in conjunction with the appropriate standard license type (EMR, EMT, AEMT, or Paramedic). Each endorsement acquired by a licensee indicates the licensee has obtained a defined set of skills and knowledge, determined and approved by the board or its designee, that expands the scope of practice of the ECP. The medical director grants permission for an ECP to utilize an endorsement, provided the specific endorsement is identified on the ECP's license.

            (q) (k) "Lead instructor" means a person who is licensed by the board, is an endorsement which indicates the endorsed licensee has attended a board-approved instructor training program conducted by the board, and is authorized competent to offer and conduct ECP courses. The lead instructor is under the supervision of the board for BLS courses and under the supervision of the board and medical director for ALS courses.

            (r) (l) "Medical director" means an unrestricted Montana licensed physician or a physician or physician assistant who holds a current unrestricted Montana license and is responsible professionally and legally responsible for training, providing medical direction, and oversight to a of licensed ECP ECPs under the medical director's supervision and/or for the training provided in an approved program/course.

            (s) (m) "Montana Statewide ECP Protocols Practice Guidelines" or "Statewide Protocols" means the written standardized protocols development guidelines developed, approved, and distributed by the board, which provides that provide guidance to medical directors and all licensed ECP ECPs licensed to practice at all levels.

            (n) "NAEMSE" means the National Association of EMS Educators.

            (t) remains the same but is renumbered (o).

            (u) (p) "NREMT" means the National Registry of Emergency Medical Technicians, an independent, not-for-profit, nongovernmental certification agency based in Columbus, Ohio.

            (v) and (w) remain the same but are renumbered (q) and (r).

            (s) "Refresher" means a program, training, or course that reviews the knowledge and skills of the current curriculum, and documents continued competence and meets curriculum requirements.

            (t) "USDOT" means United States Department of Transportation.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board determined that many of the definitions in this rule are no longer relevant either because an organization no longer exists (ABPC) or because terms are used differently in different contexts and can be stated in other ways (ALS, BLS).  The board is relocating several definitions from other rules and adding terms that are utilized in board rules.  Additionally, the board is eliminating the process of approving EMS educational courses or programs and is therefore deleting all definitions associated with that process.

 

            24.156.2705 UNPROFESSIONAL CONDUCT (1) In addition to those forms of unprofessional conduct defined in 37-1-316, MCA, the following are considered unprofessional conduct for a licensee or license applicant under Title 50, chapter 6, part 2, MCA an ECP:

            (a) conviction, including conviction following a plea of nolo contendere, of an offense involving moral turpitude, whether a misdemeanor or felony, and whether or not an appeal is pending;

            (b) conduct likely to deceive, defraud, or harm the public including, but not limited to, practicing while subject to a physical or mental condition which renders the licensee unable to safely engage in activities required of a licensee under this subchapter;

            (c) acting in such a manner as to present conduct that presents a danger to public health or safety, or to any patient including, but not limited to, incompetence, negligence, or malpractice;

            (d) making a false or misleading statement regarding the licensee's skill in connection with the activities required of a licensee under this subchapter;

            (e) use of a false, fraudulent, or deceptive statement, whether written or verbal, in connection with the activities required of a licensee under this subchapter;

            (f) having been subject to disciplinary action of another state or jurisdiction against a license or other authorization, based upon acts or conduct by the licensee similar to acts or conduct that would constitute grounds for disciplinary action under Title 37, chapter 1, MCA, or rules under this subchapter. A report from the NPDB or a certified copy of the record of the action taken by the other state or jurisdiction is evidence of unprofessional conduct;

            (g) (d) having voluntarily relinquished or surrendered a professional or occupational license, certificate, or registration in this state, or in another state or jurisdiction while under investigation or during a pending complaint;

            (h) remains the same but is renumbered (e).

            (i) (f) failure to practice within the scope of practice of the ECP licensure level and endorsements, including any restrictions determined by the ECP's medical director;

            (j) (g) failure to practice within adopted statewide and/or local protocols, policies, and procedures established and approved by the board and Montana ECP Practice Guidelines or direction, procedures, or restrictions set by the ECP's medical director;

            (k) failing to complete the required continuing education requirements established by the board when identified and while licensed as an ECP in Montana;

            (l) (h) willful disobedience of the provisions of Title 37, chapter 1, MCA, any statute or rule adopted by the board under the Board of Medical Examiners' jurisdiction, or any order of the board regarding enforcement of discipline of a licensee;

            (m) (i) habitual intemperance or repetitive excessive use of an addictive drug, alcohol, or any other substance to the extent that the use impairs the user physically or mentally; this provision does not apply to a licensee who is in compliance with an approved therapeutic regimen as described in 37-3-203, MCA;

            (n) (j) failing to furnish to the board or its designee cooperate with a lawful investigation conducted by the board or its designee, including furnishing information requested by the board or a in response to an inquiry;

            (o) failing to cooperate with a lawful investigation conducted by the board;

            (p) failing to comply with any statute or rule under the Board of Medical Examiner's jurisdiction;

            (q) (k) filing a complaint with or providing information to the board, which the licensee knows, or ought to should know, is false or misleading. This provision does not apply to any filing of complaint or providing information to the board when done in good faith under 37-1-308, MCA;

            (r) remains the same but is renumbered (l).

            (s) (m) commission of any act of sexual abuse, misconduct, or exploitation by the licensee whether or not related to the practice. The use of or the failure to use a chaperone for patient encounters in which the potential for sexual exploitation exists shall be considered in evaluating complaints of sexual exploitation related to the licensee's practice;

            (t) failing to exercise technical competence in carrying out ECP care;

            (u) remains the same but is renumbered (n).

            (v) (o) falsifying and or altering patient records or trip reports, intentionally documenting patient records or trip reports incorrectly, or failing to document patient records, or prepare trip reports;

            (w) remains the same but is renumbered (p).

            (x) (q) failing as a clinical preceptor or lead instructor, to supervise, manage, or train students practicing under the licensee's supervision, according to: state laws and rules applicable to ECPs;

            (i) scope of practice;

            (ii) generally accepted standards of patient care;

            (iii) board-approved USDOT curriculum including revisions; and

            (iv) statewide protocols, policies, and procedures.

            (y) (r) willfully harassing, abusing, or intimidating a patient, either physically or verbally; and

            (z) practicing as an ECP at any level without a current, active Montana license at that level;

            (aa) (s) failing to comply with any agreement the licensee has entered into with a program established by the board under 37-3-203, MCA;.

            (ab) any other act, whether specifically enumerated or not that in fact constitutes unprofessional conduct; and

            (ac) failing to report to the board the unprofessional conduct of other licensed ECPs.

 

            AUTH: 50-6-203, MCA

            IMP:     37-1-131, 50-6-203, MCA

 

REASON:  The board determined that this rule requires extensive revision to make it more effective for prosecuting alleged unprofessional conduct.  The board is removing duplicative language and combining several provisions throughout for simplicity, better organization, and improved readability.  The board is also adding clarifying language to several provisions to address licensee questions and assist in the prosecution of certain unprofessional conduct.

            The board is striking (1)(d) through (f) and (1)(t) as these sections unnecessarily duplicate the statutory unprofessional conduct provisions in 37-1-316, MCA.

The board is striking (1)(k) to align with 37-1-321, MCA, that provides licensees not in compliance with CE may be subject to administrative suspension.

            Lastly, the board is revising or striking several sections following recommendations by board legal counsel. The board is amending (1)(k) to remove a potential internal conflict regarding licensees filing complaints. The board is amending (1)(m) as the consideration of chaperone use in certain situations is within the prosecutor's discretion and need not be stated in this rule. To ensure licensees are well informed of what conduct the board considers unprofessional conduct, the board is striking (1)(ab) as overly vague. Lastly, it is reasonably necessary to remove (1)(ac) as the reporting of other licensees' unprofessional conduct is not mandatory for any other of the board's license types. There is no public safety reason for requiring it solely for ECPs.

            Implementation citations are being amended to accurately reflect all statutes implemented through the rule.

 

            24.156.2707 OBLIGATION TO REPORT REPORTING TO THE BOARD

            (1) remains the same.

            (2) An ECP with suspected or known impairment shall self-report to the board.  In lieu of reporting to the board, the ECP may self-report known impairment to the board-endorsed professional assistance program.

            (3) An ECP is obligated to may report suspected or known impairment of other healthcare providers to the appropriate licensing board or agency; or, in lieu of the board or agency, may report to the board-endorsed professional assistance program.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON: The board determined that this rule does not need to make reporting by ECPs obligatory in every respect.  Making the reporting of other healthcare providers voluntary would bring this rule in concert with similar rules for other board licensees.  To align with these changes, the board is amending the rule's title.

 

            24.156.2711 ECP LICENSURE QUALIFICATIONS (1) The board shall license an applicant as an ECP at the appropriate licensure level if the applicant:

            (a) remains the same.

            (b) possesses a current active or inactive NREMT or ABPC certification equal to or higher greater than the level applying applied for, or successfully completes a written and practical third-party exam examination approved by the board, or provides a current unrestricted EMR, EMT, AEMT, or paramedic license or certification in another state in which the applicant was originally tested and which has a valid and reliable complaint process;

            (c) provides all the information necessary to establish eligibility for licensure according to the licensure board's requirements as specified by the board or its designee;

            (d) possesses has obtained a high school diploma or equivalency; and

            (e) remains the same.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board is amending (1)(b) as the ABPC no longer exists and to clarify for licensing staff that "inactive" status at the NREMT is viewed equally as "active" status for purposes of licensure. The board believes this will reduce improper rejection of applications.

            The board is amending the ECP rules throughout to address questions by clarifying that the referenced ECP licensure exams are given by third parties and not the board.  The board is further amending this rule to align with current standardized department application procedures by no longer requiring submission of a physical diploma document.

 

            24.156.2713 ECP LICENSE APPLICATION (1) An applicant for an initial ECP license, at any level, shall submit an application, on a form prescribed by the board. The application must be complete and accompanied by the appropriate fees, and the following documentation:

            (a) verification of course completion for the level or above the level for which the applicant is applying; and

            (b) proof the applicant possesses a high school diploma or its equivalent;

            (c) a copy of the applicant's birth certificate or other verifiable evidence of the applicant's date of birth, such as a driver's license;

            (d) (b) documentation of a current active or inactive NREMT certification or ABPC certification equal to or greater than the level applied for which the applicant is applying, or the successful completion of a board-approved written and practical third-party examination, or current substantially equivalent licensure in a another state the board recognizes as equivalent; and.

            (e) (2) an unopened, current, and original NPDB self-query The board will obtain a query from the NPDB for each applicant.

            (2) (3)  An applicant for an ECP license who already holds a current Montana ECP license and A current Montana ECP licensee who is applying for an ECP license at a higher greater level shall submit an application, on a form prescribed by the board. The application must be complete and accompanied by the appropriate fees, and the following documentation:

            (a) documentation of a current active or inactive NREMT certification or ABPC certification equal to or greater than the level applied for which the applicant is applying, or verification of the successful completion of a board-approved written and practical examination, or current substantially equivalent licensure in a another state the board recognizes as equivalent.

            (3) (4)  An applicant for an ECP license who already holds a current Montana ECP license and A current Montana ECP licensee who is applying for an ECP license at a lower level shall submit an application and on a form prescribed by the board. The application must be complete and accompanied by the appropriate fees.

            (4) remains the same but is renumbered (5).

            (5) Incomplete applications will be returned. The applicant may correct any deficiencies, complete any requirements necessary for licensure, and resubmit the application to the board office. Failure to resubmit the deficient application within one year from the date of the original submission will be treated as a voluntary withdrawal of the application and all fees will be forfeited.

            (6)  The applicant may voluntarily withdraw the application prior to the one-year deadline set forth in (3) by submitting a withdrawal in writing written request to the board, if the application has not appeared on a board agenda. All application fees submitted will be forfeited.

            (7) After withdrawal of an application, the applicant will be required to submit a new application, including supporting documentation and appropriate fees to begin the licensing and verification process.

            (8) Completed applications will be reviewed by the board or its designee, which may request such additional information or clarification of information provided in the application as it deems reasonably necessary.

 

            AUTH: 37-1-131, 50-6-203, MCA

            IMP:     37-1-104, 37-1-131, 50-6-203, MCA

 

REASON:  The board determined it is reasonably necessary to amend this rule to remove unnecessary language, streamline the rule, and facilitate the department's standardized application procedures. For example, some requirements, such as providing proof of age and educational level, can be met through attestation and do not require physical proof.  These changes will align this rule with the proposed amendments to ARM 24.156.2711 and remove potential barriers to efficient license application processing.  Similarly, following amendment, the board will seek a National Practitioner DataBank report and not require an applicant to request one, thus reducing license application processing time. Authority citations are being amended to provide the complete sources of the board's rulemaking authority.

 

            24.156.2715 SUBSTANTIALLY EQUIVALENT EDUCATION (1) In order for the board to recognize an alternative ECP course completion, the course for an individual must have been either:

            (a) an ECP educational program reviewed and approved by the board; or

            (b) determined to be "substantially equivalent" as defined by the board.

            (1) The board or its designee shall evaluate an applicant's ECP course completed in another jurisdiction, and shall accept out-of-state courses which are determined to be substantially equivalent.

            (2) For the purposes of 37-1-304, MCA, the board defines "substantially equivalent" as ECP education and training greater than or equivalent to the board-approved USDOT curriculum standards, including revisions and statewide protocols, policies, and procedures current curriculum. Work experience obtained in the profession will not be considered as the sole basis of the applicant's qualifications.

            (3) The individual requesting review of their education to be considered as "substantially equivalent" shall submit an application on a form prescribed by the board.

            (a) Completed applications will be reviewed by the board or its designee, which may request such additional information or clarification of information provided in the application as it deems reasonably necessary.

 

            AUTH: 37-1-131, 50-6-203, MCA

            IMP:     37-1-131, 37-1-304, 37-3-203, 50-6-203, MCA

 

REASON:  The board is amending this rule to align with and further facilitate standardized department procedures and remove provisions that do not need to be duplicated in rule.  Information regarding USDOT curriculum is being removed from (2) and relocated in ARM 24.156.2701.  The board believes the amendments will simplify and streamline the evaluation of ECP courses from other jurisdictions, and address licensee and staff questions. Authority citations are being amended to provide the complete sources of the board's rulemaking authority.

 

            24.156.2718 CONTINUING EDUCATION AND REFRESHER REQUIREMENTS (1) All levels of licensed ECPs are required to complete continuing education (CE) and refresher requirements prior to their expiration date.

            (a) EMRs must complete an EMR level refresher program, which reviews the knowledge and skills of the current curriculum, and documents continued competence.

            (b) EMTs must complete 48 hours of continuing education topics contained within the original EMT course CE and an EMT refresher program, which reviews the knowledge and skills of the current curriculum, and documents continued competence.

            (c) AEMTs must complete 36 hours of continuing education topics contained within the original EMT course CE and an AEMT refresher program, which reviews the knowledge and skills of the current curriculum, and documents continued competence.

            (d) Paramedics must complete 24 hours of continuing education topics contained within the original EMT course CE and a paramedic refresher program, which reviews the knowledge and skills of the current curriculum, and documents continued competence.

            (2) CE consists of topics contained within the current curriculum of the ECP licensure level.

            (2) (3) ECPs must complete a refresher course in which a lead instructor or medical director validates knowledge and skills.

            (a) An ECP cannot build a refresher course by may not meet refresher program requirements by combining continuing education topics or offerings CE courses;.

            (a) (b) The refresher course must assess the licensee's competency, demonstrated during the course, to function at the ECP license level of the ECP license in accordance with the scope of education and practice.; and

            (b) (c) The refresher may be a course of instruction or a combination of quality improvement and quality assurance activities coordinated by an active local medical director., and the

            (i) The content must be structured to assess competency of the core knowledge and skills for the level of the ECP ECP's license.

            (ii) The refresher need not be structured in a setting of traditional classroom sessions, but may be extended throughout the biennial renewal cycle.

            (3) (4) ECPs certified by the NREMT may report completed continuing education CE and refresher course credits to the NREMT for registration purposes and also to the board to meet, in whole or in part, the requirements of (1), and (2), and (3).

            (4) (5) The lead instructor is responsible for the refresher training at the EMR and EMT levels and shall maintain records of all courses conducted including an agenda and detailed student performances that document the licensee's ability demonstrated during the refresher.

            (5) (6) The medical director is responsible for the refresher training at the endorsed EMT with endorsement(s), AEMT, and paramedic levels level and above. The medical director may assign duties as appropriate, but retains the overall responsibility for the refresher.

            (6) The lead instructor conducting a refresher course must provide an agenda and detailed student performances that document the licensee's ability demonstrated during the course of instruction to function in accordance with knowledge and skills within the original scope of education.

            (a) If audited by the board, the lead instructor must justify the content of the EMR and EMT refresher.

            (b) If audited by the board, the medical director must justify the AEMT and paramedic refresher content.

            (7) Endorsement continuing education requirements and continued competence is the responsibility of the medical director.

            (7) All ECPs shall submit upon renewal an affidavit stating that the ECP is competent in the licensure level skills, including endorsement skills.

            (a) Affidavits of EMR and EMT levels shall be signed by both the ECP and a lead instructor or medical director.

            (b) Affidavits of EMT with endorsement(s), AEMT, and paramedic levels shall be signed by both the ECP and their medical director.

            (c) The medical director may require the ECP to complete additional CE hours or training to ensure competency of endorsement skills.

            (8) Documentation of all continuing education CE and continued competence must be retained by the ECP, and made available to the board if requested upon request.

            (9) The board or their designee may conduct onsite visits of continuing educational offerings to assure the content and accuracy of the offering.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  It is reasonably necessary to amend and streamline this rule to clearly set forth the current CE and refresher requirements for ECPs and the process for renewal affidavits. The board is amending this rule to relocate the definition of "refresher" programs to the definitions rule, ARM 24.156.2701, and differentiate between CE and refresher by adding (2).  The board is striking (7) and further clarifying the medical director responsibilities in (7)(c) and ARM 24.156.2732(6).

            Following a concern by legal staff that onsite visits may be conducted without guidelines, the board is striking (9). Following amendment, the board will rely on CE certificate submissions and CE reporting to verify proper course content.

 

            24.156.2719 EXPIRED LICENSE (1) An expired ECP license may be reactivated upon completion of an expired license renewal application. To reactivate an expired license the applicant an ECP shall:

            (a) complete an expired license renewal application and submit it to the board meet department requirements under ARM 24.101.403 and 24.101.408; and

            (b) pay the license fee plus late penalty fee as specified in ARM 24.101.403 for each year the license has expired up to two years; and

            (c) (b) possess a current NREMT or ABPC certification for the appropriate level of licensure or higher, or successfully complete a board-approved written and practical examination or provide documentation of completion of all renewal requirements required for the ECP license being reactivated under ARM 24.156.2718.

            (2) The provisions of ARM 24.101.408 apply.

 

            AUTH: 37-1-131, 50-6-203, MCA

            IMP:     37-1-141, 50-6-203, MCA

 

REASON: The board determined it is reasonably necessary to amend this rule to remove provisions duplicated in other rules and insert references to those rules.  Because ABPC no longer exists, the board is removing its reference from all rules. Authority citations are being amended to provide the complete sources of the board's rulemaking authority.

 

            24.156.2731 FEES (1) through (1)(i) remain the same.

            (j) program approval                                                                                         250

            (k) course approval                                                                                            15

            (l) education review for determination of "substantially equivalent"         25

            (2) and (3) remain the same.

 

            AUTH: 37-1-134, 50-6-203, MCA

            IMP:     37-1-134, 37-1-141, 50-6-203, MCA

 

REASON:  Because the board will no longer approve education courses or programs, it is reasonably necessary to amend this rule to remove the unnecessary fees.  The board estimates the proposed elimination of the fee for course approval will affect 3 requesters and result in a decrease in annual revenue of $45. The remaining fee changes will have zero effect on board revenue based on FY 2018 fee collections.

 

            24.156.2732 MEDICAL DIRECTION (1) and (1)(a) remain the same.

            (b) provide proof of completion of a board-specified approved medical director training program or a board-approved exemption from the training on a form provided by the board.

            (2) A physician or physician assistant who fails to comply with the requirements of (1) may not function as a medical director.

            (3) remains the same but is renumbered (2).

            (3) The medical director overseeing an ECP may grant or restrict the ECP's practice or utilization of any endorsement.

            (4) The medical director must assure maintain and have access to records of all ECPs for whom the director provides medical oversight. These records must include, but are not limited to document:

            (a) remains the same.

            (b) date when medical oversight began and at what level the ECP is authorized to function practice; and

            (c) any changes to limit or approve the ECP's ability authorization to function at the ECP's current licensure level including endorsement(s).

            (5) The medical director must develop a process to assure continued appropriate continuously meet the applicable standard of medical practice and patient care. This process may include regular review of patient care reports (PCR), direct observation of care, skills demonstrations, and ongoing involvement in ECP education. Documentation of these activities must be maintained by the medical director.

            (6) The medical director is responsible for assessing competency of skills required for endorsements held by ECPs under the medical director's supervision and shall sign an affidavit stating such competence as required under ARM 24.156.2718.

            (6) (7) A medical director may assign duties where appropriate, but retains the responsibility for all assigned duties. This includes delegation of:

            (a) The medical director may delegate local offline medical direction responsibilities to another unrestricted Montana licensed physician or physician assistant.; and

            (b)  maintenance of records required under (4).

            (7) (8) The medical director will approve and review the offering of online medical control.

            (a) Online medical control which must be provided by any unrestricted Montana licensed physician or physician assistant who has been contacted for this purpose.

            (8) (9) The A medical director may cease medical oversight by providing shall provide written notice to the ECP and the board upon discontinuing medical oversight.

            (9) The medical director of an ECP course shall be responsible for the overall quality, consistency, and management of the ECP course in which they agree to provide medical oversight. The medical director may delegate duties where appropriate.

            (a) Medical oversight of an ECP course consists of review of agenda, selection of instructors, review of evaluation tools, and review of clinical offerings and objectives.

            (b) Medical direction of an AEMT or paramedic course consists of approval of agenda, approval and selection of instructors, involvement in the development and implementation of evaluation tools, participation as an instructor, approval of clinical offerings and objectives to be met in clinical components, and identification of successful course completion for each student.

            (10) The medical director shall be responsible for and approve the a system to assure the inventory, storage, and security of all the medications utilized by the ECPs to whom the medical director provides medical oversight. The medical director may delegate the day-to-day duties where appropriate, but retains the overall responsibility.

            (11) The board or their designee may conduct onsite visits with medical directors for technical assistance and/or to assure compliance.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  It is reasonably necessary to reorganize and streamline this rule to clearly set forth the duties and responsibilities of medical directors. Section (2) is being stricken as the provision is adequately addressed in ARM 24.156.2705, the unprofessional conduct rule. The board is adding (3) by relocating language previously in the definition of "endorsement" in ARM 24.156.2701. It is reasonably necessary to add (6) to incorporate competency assessment from ARM 24.156.2718. The board is also amending this rule to relocate (9) to New Rule I, regarding ECP training courses, as a more logical location.

            Following a concern by legal staff that onsite visits may be conducted without guidelines, the board is striking (11). Following amendment, the board will rely on the medical director's attestation of the ECP's competency upon the ECP's renewal.

 

            24.156.2751 LEVELS OF ECP LICENSURE INCLUDING ENDORSEMENTS

            (1) remains the same.

            (a) ECP – Emergency Medical Responder (EMR), licenses:

            (i) remains the same.

            (ii) naloxone; and

            (iii) lead instructor.

            (b) ECP – Emergency Medical Technician (EMT) licenses:

            (i) and (ii) remain the same.

            (iii) IV and IO (intravenous infusion and intraosseous infusion) maintenance; and

            (iv) remains the same.

            (v) naloxone; and

            (vi)  lead instructor.

            (c) ECP - Advanced EMT (AEMT) licenses:

            (i) AEMT medication; and

            (ii) AEMT-99; and

            (iii) lead instructor.

            (d) ECP - Paramedic licenses:

            (i) paramedic critical care transport paramedic; and

            (ii) lead instructor.

 

            AUTH: 50-6-203, MCA

            IMP:     37-1-131, 50-6-203, MCA

 

REASON:  The board is abbreviating and reorganizing the three levels of ECP licensure for consistency and ease of use.  Additionally, the board is adding new endorsements for naloxone and lead instructor as they currently are treated as endorsements but have not been previously recognized in rule. Implementation citations are being amended to accurately reflect all statutes implemented through the rule.

 

            24.156.2752 ECP ENDORSEMENT APPLICATION (1) An applicant for an ECP endorsement, at any level, shall submit an application on a form prescribed by the board., The application must be complete and accompanied by the appropriate fee, and the following documentation:

            (a) the applicant's verification of knowledge and skills as identified on a form provided by the board for each endorsement level for which the applicant is applying.; and

            (2) (b) An applicant for an ECP endorsement must have an attestation of current Montana ECP license in Montana at the appropriate level to qualify for the endorsement.

            (3) Incomplete applications will be returned. The applicant may correct any deficiencies, complete any requirements necessary, and resubmit the application to the board office. Failure to resubmit the deficient application within one year from the date of the original submission will be treated as a voluntary withdrawal of the application and all fees will be forfeited.

            (4) (2) The applicant may voluntarily withdraw the application prior to the one-year deadline set forth in (3) by submitting a withdrawal in writing written request to the board. All application fees submitted will be forfeited.

            (5) After withdrawal of an application, the applicant will be required to submit a new application, including supporting documentation and appropriate fees to begin the endorsement and verification process.

            (6) Completed applications will be reviewed by the board or its designee, which may request such additional information or clarification of information provided in the application as it deems reasonably necessary.

 

            AUTH: 37-3-203, 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board determined it is reasonably necessary to amend this rule to align with and further facilitate the department's standardized application procedures, applicable to all boards. Several provisions are contained in the standard procedures and do not need to be duplicated in rule. Authority citations are being amended to provide the complete sources of the board's rulemaking authority.

 

            24.156.2761 PROCEDURES FOR REVISION OF BOARD-APPROVED MONTANA ECP CURRICULUM AND STATEWIDE PROTOCOLS PRACTICE GUIDELINES OR CURRICULUM  (1) At the regularly scheduled board meetings a A medical director may initiate submit a petition for revisions to the board-approved Montana ECP curriculum and/or statewide protocols, policies, and procedures Practice Guidelines or curriculum.

            (2) The petition must be submitted on a board-approved form prescribed by the board with the following supporting documentation:

            (a) a written recommendation and/or position statement for the revision to the board-approved curriculum and/or statewide protocols, policies, and procedures; and

            (b) literature supporting the petitioner's recommendations and/or position.

            (3) Upon receiving the petition application, the board will shall proceed as follows:

            (a) the board will consider board's medical direction committee (committee)

shall review an initial petition to determine whether to place the petition as an action item on the agenda for the next regularly scheduled board meeting;

            (b) the board may request an opinion of the medical direction committee and may accept public comment regarding the petition; and

            (c)  the committee shall present the board with a written recommendation; and

            (c) (d) the board will shall consider the comments committee's recommendation and take action on the petition no sooner than the next regularly scheduled board meeting.

            (4) The board shall approve the proposed revision when:

            (a) when it is demonstrated to the satisfaction of the board that granting the petitioner's request for revision of the board-approved curriculum and/or statewide protocols, policies, and procedures is necessary to provide appropriate standards of medical care;

            (b) where in the case of an individual service approval, the board finds that the public's interest in granting the revision clearly outweighs the interest of maintaining uniform board-approved USDOT curriculum, including revisions and/or statewide protocols, policies, and procedures Montana ECP Practice Guidelines or curriculum; and

            (c) where in the opinion of the board, concludes the revisions will provide adequate protect public health, safety, and welfare protection.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board is amending this rule to replace "protocols" with "practice guidelines" and better reflect their purpose and the intent of the rule.  The board concluded that requests to revise practice guidelines will be initially considered by the medical direction committee, without having to first go before the full board.  The board believes this will greatly streamline this process. The board is also striking provisions regarding standards other than the practice guidelines and redundant language for consistency and simplicity.

 

            24.156.2771 ECP SCOPE OF PRACTICE (1) An ECP licensed or endorsed at the BLS an EMR or EMT level may perform any acts allowed within the ECP's licensure or endorsement level when:

            (a) operating independently within the most current version of the Montana statewide protocols Montana ECP Practice Guidelines; or

            (b) under the medical oversight from of a medical director who is taking responsibility for the ECP; or

            (c) operating on a Montana licensed EMS with a medical director; or

            (d) remains the same but is renumbered (c).

            (2) An ECP licensed or endorsed at the ALS an EMT with endorsement(s), AEMT, or paramedic level may perform any acts allowed within the ECP's licensure level or endorsement level when:

            (a) under medical oversight from of a medical director who is taking responsibility for the ECP; or

            (b) operating on a Montana licensed EMS with a medical director; or

            (c) remains the same but is renumbered (b).

            (3) An ECP legally licensed in good standing in the state from which they are responding from may perform within their licensed protocols scope of practice at the level licensed, when functioning as a member of a licensed ambulance service which that finds itself within the boundaries of Montana, while:

            (a)  responding to an emergency where the border is not clearly known, or when;

            (b) responding on to an emergency in accordance to a mutual aid agreement with a Montana licensed EMS service; or

            (c)  when conducting a routine transfer to or from a Montana medical facility. The ECP must perform within the acts allowed at the level for which the ECP is licensed.

            (4) A student may perform beyond the level of his or her individual licensure when functioning as a student in a board-approved an ECP training course conducted in accordance with board rules or if the student is including participating in a clinical component of a course or program of instruction originating in another state that has a clinical contract with a Montana healthcare facility or a Montana-licensed EMS agency and functions under the direct supervision of a clinical preceptor licensed in Montana. The student must perform within the Montana scope of practice at the level for which the student is a student candidate.

            (5) Except as provided in (3) (4), an ECP may not perform any acts that are beyond the ECP's level of licensure or endorsement.

            (6) The medical director may limit the functioning scope of an ECP due to community needs and/or issues with maintaining competency. If, after remediation and review of an individual ECP's performance, the medical director has continuing concerns as to the ECP's ability to perform to the ECP's scope of practice, this shall be reported to the board.

            (7) An ECP currently licensed and in good standing in another state may function during a state and/or federally managed incident under in compliance with the Montana statewide protocols, policies, and procedures ECP Practice Guidelines, but shall comply with all of the following:

            (a) limit the ECP's practice shall be limited to the duration of the state and/or federally managed incident;

            (b) practice shall be conducted within the geographic area, whether on federal, state, or private land, designated as being within the state and/or federally managed incident;

            (c) practice at the basic level, even if the ECP is licensed at a higher level in another state, unless the individual is licensed at an ALS EMT with endorsement(s), AEMT, or paramedic level, and the federally managed incident has medical control direction provided by a Montana licensed physician approved by the board as a medical director, and the physician authorizes the individual to function beyond the basic level;

            (d) and (e) remain the same.

            (8) The board or their designee may conduct onsite visits of state and/or federally managed incidents to assure compliance.

            (9) remains the same.

 

            AUTH: 50-6-203, MCA

            IMP:     37-1-131, 50-6-203, MCA

 

REASON:  The board is amending this rule to replace "protocols" with "practice guidelines" or "scope of practice" for consistency in the rules.  Additionally, the board is replacing ALS and BLS with the more specific EMR or EMT licensure levels.  It is reasonably necessary to amend this rule throughout for better organization and to comply with ARM formatting requirements. Implementation citations are being amended to accurately reflect all statutes implemented through the rule.

 

            5. The proposed new rules are as follows:

 

            NEW RULE I ECP TRAINING COURSES (1) An individual, corporation, partnership, or any other organization may conduct ECP training courses.  All ECP training courses or programs must include the following:

            (a)  current USDOT curriculum;

            (b)  Montana ECP Practice Guidelines;

            (c)  statutes and rules governing ECPs in Montana;

            (d)  a final competency evaluation; and

            (e)  certificate of successful completion which states:

            (i)  start and end dates of the course;

            (ii)  topics taught; and

            (iii)  names of designated lead instructor and/or medical director.

            (2)  A clinical component must be included and documented in the following levels of ECP courses:

            (a)  EMT course participants must complete a minimum of ten hours of clinical experience during which the student shall:

            (i)  observe patient care on at least 5 patients; and

            (ii)  perform a patient assessment on at least 5 adult patients.

            (b)  AEMT course participants shall:

            (i)  properly administer medications at least 10 times to live patients;

            (ii)  successfully access the venous circulation at least 15 times on live patients of various age groups;

            (iii)  ventilate at least 15 live patients of various age groups;

            (iv)  perform an advanced patient assessment on at least 15 adult patients, 5 pediatric patients, and 10 trauma patients;

            (v)  perform an advanced patient assessment, formulate and implement a treatment plan on at least 10 patients with chest pain;

            (vi)  perform an advanced patient assessment, formulate and implement a treatment plan on at least 10 adult patients and 3 pediatric patients with dyspnea/respiratory distress;

            (vii)  perform an advanced patient assessment, formulate and implement a treatment plan on at least 10 patients with altered mental status; and

            (viii)  serve as the team leader for at least 20 prehospital emergency responses.

            (c)  Paramedic course participants shall:

            (i)  properly administer medications at least 15 times to live patients;

            (ii)  successfully intubate at least 5 live patients;

            (iii)  successfully access the venous circulation at least 25 times on live patients of various age groups;

            (iv)  ventilate at least 20 live patients of various age groups;

            (v)  perform a comprehensive patient assessment on at least 50 adult patients, 30 pediatric patients (including newborns, infants, toddlers, and school age), 40 trauma patients, 30 geriatric patients, 10 obstetric patients, and 20 psychiatric patients;

            (vi)  perform a comprehensive patient assessment, formulate and implement a treatment plan on at least 30 patients with chest pain;

            (vii)  perform a comprehensive patient assessment, formulate and implement a treatment plan on at least 20 adult patients and 8 pediatric patients (including infants, toddlers, and school age) with dyspnea/respiratory distress;

            (viii)  perform a comprehensive patient assessment, formulate and implement a treatment plan on at least 10 patients with syncope;

            (ix)  perform a comprehensive patient assessment, formulate and implement a treatment plan on at least 20 patients with abdominal complaints;

            (x)  perform a comprehensive patient assessment, formulate and implement a treatment plan on at least 20 patients with altered mental status; and

            (xi)  serve as the team leader for at least 50 prehospital emergency responses.

            (3)  All EMR and EMT level courses must designate a lead instructor who shall maintain overall responsibility for the quality, consistency, and management of the course.

            (4)  All EMT with endorsement(s), AEMT, and paramedic level courses must designate a lead instructor and a medical director.  The lead instructor is under the supervision of the board and medical director for these courses.

            (5)  The medical director of an ECP course shall be responsible for the overall quality, consistency, and management of the ECP course in which they agree to provide medical oversight. The medical director may delegate duties where appropriate.

            (a)  Medical direction of an EMR or EMT level course consists of review of agenda, selection of instructors, review of evaluation tools, and review of clinical offerings and objectives.

            (b)  Medical direction of an EMT with endorsement(s), AEMT, or paramedic level course consists of approval of agenda, approval and selection of instructors, involvement in the development and implementation of evaluation tools, participation as an instructor, approval of clinical offerings and objectives to be met by clinical components, and verification of successful course completion for each student.

            (6)  The lead instructor of an EMR course shall:

            (a)  document student skill and proficiency on board-approved forms;

            (b)  complete the course within six months of the date the course commences; and

            (c)  provide at least one instructor per six students when practical skills are taught.

            (7)  The lead instructor of an EMT course shall:

            (a)  document student skill and proficiency on board-approved forms;

            (b)  complete the course within 12 months of the date the course commences;

            (c)  provide at least one instructor per six students when practical skills are taught;

            (d)  provide the clinical experience as specified under (2)(a); and

            (e)  have access to a medical director who is available for consult.

            (8)  The lead instructor and medical director of an AEMT or paramedic course shall:

            (a)  document student skill and proficiency on board-approved forms;

            (b)  provide clinical experience as specified under (2)(b) and (c);

            (c)  complete the course in the following time frames:

            (i)  AEMT course within 18 months from the starting date of the course; and

            (ii)  paramedic course within 24 months from the starting date of the course;

            (d)  provide clinical experiences with no fewer than one clinical preceptor for every two students; and

            (e)  provide sufficient patient volume to allow students to complete all clinical experiences within the course dates.

            (9)  Requests for extension of required course completion times stated in (8)(c) must be submitted in writing and may be granted by the board or its designee.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board determined is it reasonably necessary to repeal ARM 24.156.2741 and adopt New Rule I to locate all the board's requirements for ECP education courses in a single rule.  As stated previously and to align with changes proposed elsewhere in this notice, the board is adopting this rule to specify that the board will no longer approve ECP training courses as lead instructors and medical directors will bear full responsibility for the courses.  This will relieve the department of administrative functions regarding ECP courses while still maintaining compliance oversight for licensees who fail to meet their responsibilities under the rule.

 

            NEW RULE II FINAL PRE-LICENSING EXAMINATIONS (1)  A candidate must successfully complete an ECP course for the level of licensure the candidate is seeking to be eligible to take a final pre-licensing practical or written examination.

            (2) To be eligible for licensure at any ECP level, a candidate must successfully complete, in this order, the following:

            (a) a final pre-licensing practical examination; and

            (b) a final pre-licensing written examination.

            (3)  A candidate must have completed the practical examination in (2)(a) within the past two years to be eligible to take the written examination in (2)(b).

            (4) A board-approved third party may create and/or conduct final pre-licensing examinations.

            (5) All final pre-licensing practical examinations must test all skills required by the NREMT 2016 Psychomotor Examination for the level of licensure the candidate is seeking.

            (6) A medical director shall be responsible for conducting final pre-licensing practical examinations, other than those conducted by NREMT, and may delegate duties when appropriate.

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  It was determined that the current rule on ECP examinations, ARM 24.156.2745, required such extensive amendments that repealing it and adopting an entirely new examination rule would be clearer and more efficient.  The board is adopting this new rule to specify its application to third-party examinations given for final licensure and/or NREMT certification and not the examinations given during an ECP course. The department also plans to rely on specific standards set in 2016 by NREMT for the practical examinations instead of relying on a Montana-specific document which is subject to change and extensive upkeep to remain current on the board's web site.

 

            6. The rules proposed to be repealed are as follows:

 

            24.156.2708 COMPLAINTS INVOLVING PREHOSPITAL CARE, INTERFACILITY CARE, EMERGENCY MEDICAL TECHNICIANS (ECPs), OR EMERGENCY MEDICAL SERVICE (EMS) OPERATIONS 

 

            AUTH: 37-3-203, 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board is repealing this rule as it is an unnecessary duplication of 50-6-105, MCA.

 

            24.156.2717 ECP LICENSE RENEWAL 

 

            AUTH: 50-6-203, MCA

            IMP:    37-1-131, 37-1-141, 37-1-306, 50-6-203, MCA

 

REASON:  The board is repealing this unnecessary rule because the department administers a standardized renewal process for all professional and occupational licensure boards.

 

            24.156.2741 ECP TRAINING PROGRAM/COURSE APPLICATION AND APPROVAL 

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board determined it is reasonably necessary to repeal this rule because amending it would be very complicated and confusing. The board believes that full repeal and replacement with New Rule I will be clearer and more effective.

 

            24.156.2745 EXAMINATIONS 

 

            AUTH: 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  The board concluded that full repeal of this rule and replacement with New Rule II, instead of numerous complicated amendments, will be clearer and more effective.

 

            24.156.2754 INITIAL ECP COURSE REQUIREMENTS 

 

            AUTH: 50-6-203, MCA

            IMP:     37-1-131, 50-6-203, MCA

 

REASON:  The board is repealing this rule and relocating relevant provisions to New Rule I.

 

            24.156.2755 POST-COURSE REQUIREMENTS 

 

            AUTH: 37-3-203, 50-6-203, MCA

            IMP:     50-6-203, MCA

 

REASON:  It is reasonably necessary to repeal this rule because the board and department staff will no longer conduct pre-course or post-course approvals.

 

            24.156.2757 ECP CLINICAL REQUIREMENTS 

 

            AUTH: 50-6-203, MCA

            IMP:     37-1-131, 50-6-203, MCA

 

REASON:  The board is repealing this rule and relocating relevant provisions to New Rule I.

 

            7. Concerned persons may present their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to the Board of Medical Examiners, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513, by facsimile to (406) 841-2305, or e-mail to dlibsdmed@mt.gov, and must be received no later than 5:00 p.m., February 22, 2019.

 

            8. An electronic copy of this notice of public hearing is available at www.medicalboard.mt.gov (department and board's web site). Although the department strives to keep its web sites accessible at all times, concerned persons should be aware that web sites may be unavailable during some periods, due to system maintenance or technical problems, and that technical difficulties in accessing a web site do not excuse late submission of comments.

 

            9. The board maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this board. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies that the person wishes to receive notices regarding all board administrative rulemaking proceedings or other administrative proceedings. The request must indicate whether e-mail or standard mail is preferred. Such written request may be sent or delivered to the Board of Medical Examiners, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513; faxed to the office at (406) 841-2305; e-mailed to dlibsdmed@mt.gov; or made by completing a request form at any rules hearing held by the agency.

 

            10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

 

            11. Regarding the requirements of 2-4-111, MCA, the board has determined that the amendment of ARM 24.156.2701, 24.156.2705, 24.156.2707, 24.156.2711, 24.156.2713, 24.156.2715, 24.156.2718, 24.156.2719, 24.156.2731, 24.156.2732, 24.156.2751, 24.156.2752, 24.156.2761, and 24.156.2771 will not significantly and directly impact small businesses.

            Regarding the requirements of 2-4-111, MCA, the board has determined that the adoption of New Rules I and II will not significantly and directly impact small businesses.

            Regarding the requirements of 2-4-111, MCA, the board has determined that the repeal of ARM 24.156.2708, 24.156.2717, 24.156.2741, 24.156.2745, 24.156.2754, 24.156.2755, and 24.156.2757 will not significantly and directly impact small businesses.

            Documentation of the board's above-stated determinations is available upon request to the Board of Medical Examiners, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513; telephone (406) 841-2360; facsimile (406) 841-2305; or to dlibsdmed@mt.gov.

 

            12. Ian Marquand, Executive Officer, has been designated to preside over and conduct this hearing.

 

	BOARD OF MEDICAL EXAMINERS TANYA BREKKE, L.AC., PRESIDENT
/s/ DARCEE L. MOE Darcee L. Moe Rule Reviewer	/s/ GALEN HOLLENBAUGH Galen Hollenbaugh, Commissioner DEPARTMENT OF LABOR AND INDUSTRY

                                                                                   

 

            Certified to the Secretary of State January 15, 2019.