Non-Emergency Patient Transport Regulations 2016

Version No. 002

Non-Emergency Patient Transport Regulations 2016

S.R. No. 28/2016

Version incorporating amendments as at
30 November 2021

TABLE OF PROVISIONS

Regulation Page

Part 1—Preliminary 1

1 Objective 1

2 Authorising provision 1

3 Commencement 1

4 Revocation 1

5 Definitions 2

6 Definition of low acuity patient 8

7 Definition of medium acuity patient 8

8 Definition of high acuity patient 9

Part 2—Transport of patients 10

Division 1—Classes of non-emergency patient transport service 10

9 Classes of non-emergency patient transport service 10

Division 2—Criteria for transportation 10

10 Criteria to be complied with before patient is transported 10

Division 3—Transporting patients 12

11 Transport of low acuity patients 12

12 Staffing and equipment of vehicles used for the transport of medium acuity patients 12

13 Staffing and equipment of vehicles used for the transport of high acuity patients 13

14 High acuity or medium acuity patient must not be transported with another patient 13

Division 4—Requirements applicable to all patients 13

15 Restriction on transport of patients 13

16 Handover notes and other documents 14

17 When clinical advice must be obtained before loading a patient 14

18 Carers accompanying patients 15

Part 3—Staffing of non-emergency patient transport services 16

19 Competencies for staff of non-emergency patient transport services 16

20 Assessment of competency 18

21 Skills maintenance training 18

22 Staff identification 19

Part 4—Licensing 21

Division 1—Applications 21

23 Application for approval in principle 21

24 Application for variation or transfer of approval in principle 21

25 Application for a non-emergency patient transport service licence 21

26 Conditions on licences 22

27 Application to renew a licence 23

27A Application to transfer a licence 23

28 Application to vary a licence 23

Division 2—Quality assurance plans 24

29 Development, contents and accreditation of quality assurance plan 24

30 Compliance with quality assurance plan 25

31 Audit of quality assurance plan 25

32 Revocation, suspension or expiry of accreditation of quality assurance plan 26

Division 2A—Occupational health and safety plan 26

32A Development and contents of occupational health and safety plans 26

32B Compliance with occupational health and safety plan 27

32C Audit of occupational health and safety plan 27

32D Revocation, suspension or expiry of occupational health and safety plan 28

Division 3—Other matters during course of licence 28

33 Critical incidents 28

34 Annual report 28

Part 5—Clinical governance 30

35 Clinical oversight committee 30

36 Responsibilities of committee 30

36A Meetings of committee 31

36B Staff surveys 32

Part 6—Records 33

37 Records to be kept 33

38 Patient care records 33

39 Staff records 35

40 Records of an aeromedical service 36

Part 7—Patient rights and information 37

41 Establishment of complaints register 37

42 Investigation of complaints 37

43 Contact details of a provider 38

44 Provision of information brochure 38

45 Content of information brochure 38

Part 8—Infection control 39

46 Infection control management plan 39

47 Vehicles 40

Part 9—Provision, inspection and maintenance of vehicles and equipment 42

48 Maintenance of vehicles and equipment 42

49 Records of maintenance 42

49A Mileage of vehicle 43

49B Exemption from vehicle mileage limit 43

50 Interiors of road vehicles 43

51 Equipment 46

52 Communication devices 47

52A Change to vehicle category code of vehicle 47

Part 10—Insurance 48

53 Public and professional liability insurance 48

Part 11—Aeromedical services 49

54 Report of breach of CASA requirements 49

55 Aircraft equipment 49

56 Configuration 49

57 Stowage 50

58 Loading 50

59 Cabin 51

60 Medical equipment 51

61 Other equipment requirements 52

Part 12—Transitional provisions 53

62 Transitional provision—mileage 53

63 Transitional provision—minimum separation requirement 53

64 Transitional provision—power lift stretchers and lifting cushions 53

Schedule 1—Application for approval in principle to operate a non-emergency patient transport service 55

Schedule 2—Application for variation or transfer of certificate of approval in principle to operate a non-emergency patient transport service 57

Schedule 3—Application for a non‑emergency patient transport service licence 59

Schedule 4—Application for the renewal of a non-emergency patient transport service licence 61

Schedule 4A—Application for transfer of licence to operate a non-emergency patient transport service 63

Schedule 5—Application for variation of a non-emergency patient transport service licence 65

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Endnotes 68

1 General information 68

2 Table of Amendments 70

3 Amendments Not in Operation 71

4 Explanatory details 72

Version No. 002

Non-Emergency Patient Transport Regulations 2016

S.R. No. 28/2016

Version incorporating amendments as at
30 November 2021

Part 1—Preliminary

1 Objective

The objective of these Regulations is to prescribe standards and requirements for the provision of non-emergency patient transport services under the Non-Emergency Patient Transport Act 2003, including standards for the safety and quality of care of patients using the services.

2 Authorising provision

These Regulations are made under section 64 of the Non-Emergency Patient Transport Act 2003.

3 Commencement

These Regulations come into operation on 20 April 2016.

4 Revocation

The following Regulations are revoked—

(a) the Non-Emergency Patient Transport Regulations 2005[1];

(b) the Non-Emergency Patient Transport Amendment Regulations 2010[2];

(c) the Non-Emergency Patient Transport Amendment Regulations 2014[3].

5 Definitions

(1) In these Regulations—

accreditation body means a body that is accredited by—

(a) the Joint Accreditation System of Australia and New Zealand; or

(b) the International Society for Quality in Healthcare; or

(c) a body nominated by the Secretary under subregulation (2);

Reg. 5(1) def. of active management inserted by S.R. No. 148/2021 reg. 5(1).

active management, in relation to a patient, means the patient requires treatment from first contact to last contact to maintain a stable clinical condition;

Reg. 5(1) def. of adverse event revoked by S.R. No. 148/2021 reg. 5(2).

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Reg. 5(1) def. of adverse patient safety event inserted by S.R. No. 148/2021 reg. 5(1).

adverse patient safety event means an event that results in harm or injury to a patient;

aeromedical service means a non-emergency patient transport service that transports patients by air;

aged care service has the same meaning as it has in the Aged Care Act 1997 of the Commonwealth;

Ambulance Service—Victoria has the same meaning as in section 3(1) of the Ambulance Services Act 1986;

Reg. 5(1) def. of ambulance transport attendant inserted by S.R. No. 148/2021 reg. 5(1).

ambulance transport attendant means a person employed or engaged by a non-emergency patient transport service primarily—

(a) to provide care and monitoring to low acuity patients, or medium acuity patients during their transport to or from a medical service; and

(b) to assist other staff members to provide care and monitoring to high acuity patients during their transport to or from a medical service;

Reg. 5(1) def of Automated External Defibrillator inserted by S.R. No. 148/2021 reg. 5(1).

Automated External Defibrillator means an automated external defibrillator that provides the operator with an audible or visible prompt to discharge the defibrillator to deliver a shock to the patient when it recognises a shockable rhythm;

CASA means the Civil Aviation Safety Authority established by the Civil Aviation Act 1988 of the Commonwealth;

Reg. 5(1) def. of certificate of road-worthiness inserted by S.R. No. 148/2021 reg. 5(1).

certificate of roadworthiness means a certificate of roadworthiness issued under Division 5 of Part 6 of the Road Safety (Vehicles) Regulations 2021[4];

Reg. 5(1) def. of clinic transport service vehicle inserted by S.R. No. 148/2021 reg. 5(1).

clinic transport service vehicle means a vehicle used for the purpose of transporting ambulant low acuity patients to or from medical appointments, including a vehicle that is not equipped with a stretcher or a hoist vehicle;

crew member means a person staffing a vehicle when it is used by or on behalf of a provider for, or in connection with, the transportation of a patient;

Reg. 5(1) def. of critical incident revoked by S.R. No. 148/2021 reg. 5(3).

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Department means the Department of Health and Human Services;

Reg. 5(1) def. of full driver licence inserted by S.R. No. 148/2021 reg. 5(1).

full driver licence has the same meaning as in section 3(1) of the Road Safety Act 1986;

high acuity patient has the meaning given in regulation 8;

Reg. 5(1) def. of hoist vehicle inserted by S.R. No. 148/2021 reg. 5(1).

hoist vehicle is a vehicle equipped with a hoist to lift a patient into and out of the vehicle;

Reg. 5(1) def. of infection control guidelines amended by S.R. No. 148/2021 reg. 5(4).

infection control guidelines means the National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) published by the Commonwealth;

infectious disease means a human illness or condition due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected person to another person by indirect contact, airborne transmission or respiratory droplet;

intervention means any treatment which may be administered by staff involved in the care of a high acuity patient or a medium acuity patient, and includes any invasive procedure;

Reg. 5(1) def. of licence holder inserted by S.R. No. 148/2021 reg. 5(1).

licence holder means a person who holds a non‑emergency patient transport service licence;

low acuity patient has the meaning given in regulation 6;

management, in relation to the treatment of a patient, includes the administration of those drugs that may be administered by staff involved in treating the patient, and other general treatment, not including intervention;

medium acuity patient has the meaning given in regulation 7;

monitoring, in relation to the treatment of a patient, includes—

(a) monitoring of cardiac, respiratory, metabolic, neurological or fluid status or any combination of them; and

(b) monitoring of equipment;

nurse means—

(a) a registered nurse; or

(b) a person registered in Division 2 of the Register of Nurses kept by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, other than as a student;

Reg. 5(1) def. of patient transport officer inserted by S.R. No. 148/2021 reg. 5(1).

patient transport officer means a person employed or engaged by a non-emergency patient transport service primarily—

(a) to provide care and monitoring to low, acuity patients during their transport to or from a medical service; and

(b) to assist other staff members to provide care and monitoring to low, medium or high acuity patients during their transport to or from a medical service;

provider means a person who operates a non‑emergency patient transport service and—

(a) holds a non-emergency patient transport service licence; or

(b) is, or belongs to a class of person, referred to in a declaration made under section 5(2) of the Act;

public road has the same meaning as in the Road Management Act 2004;

quality assurance plan means a plan referred to in regulation 29 that is certified by an accreditation body from which a licence holder has obtained quality accreditation;

registered nurse means a person registered in Division 1 of the Register of Nurses kept by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, other than as a student;

Reg. 5(1) def. of registered paramedic inserted by S.R. No. 148/2021 reg. 5(1).

registered paramedic, mean a person registered in the Register of Paramedics kept by the Paramedicine Board of Australia under the Health Practitioner Regulation National Law, other than as a student;

registered training organisation means an organisation registered by—

(a) the National Vocational Education and Training Regulator established under section 155 of the National Vocational Education and Training Regulator Act 2011 of the Commonwealth; or

(b) the Tertiary Education Quality and Standards Agency established under section 132 of the Tertiary Education Quality and Standards Agency Act 2011 of the Commonwealth;

Reg. 5(1) def. of sentinel event inserted by S.R. No. 148/2021 reg. 5(1).

sentinel event means an unexpected and adverse patient safety event that occurs infrequently in the provision of services by a non-emergency patient transport service and results in the death of, or serious physical or psychological injury to, a patient as a result of system and process deficiencies at the non-emergency patient transport service;

Reg. 5(1) def. of shock advisory external defibrillator revoked by S.R. No. 148/2021 reg. 5(5).

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Reg. 5(1) def. of the Act substituted by S.R. No. 148/2021 reg. 5(6).

the Act means the Non-Emergency Patient Transport and First Aid Services Act 2003;

time critical, in relation to the condition of a patient, means that the condition is such that immediate medical attention is necessary and an emergency response by an ambulance service is required.

(2) The Secretary, by notice published in the Government Gazette, may nominate as an accreditation body a body that, in the opinion of the Secretary, is internationally recognised and experienced in the accreditation of health care services.

6 Definition of low acuity patient

A low acuity patient is a patient who has one or more of the following conditions—

(a) impaired cognitive functioning requiring supervision;

(b) if the patient is not transported by an aeromedical service, chronic diagnosed shortness of breath in relation to which there has been no recent change.

7 Definition of medium acuity patient

A medium acuity patient is a patient who requires—

(a) active management or intervention; or

(b) specialised equipment requiring monitoring; or

(c) observation and monitoring of an intravenous infusion that does not contain any vasoactive agent other than glyceryl trinitrate.

8 Definition of high acuity patient

(1) A high acuity patient is a patient who requires—

(a) active management or intervention; and

(b) one or more of the following—

(i) cardiorespiratory support;

(ii) a higher level of care than that required for the transport of a medium acuity patient;

(iii) observation and monitoring of an intravenous infusion that contains vasoactive agents;

(iv) transport by PIPER's neonatal emergency transport service, PIPER's paediatric emergency transport service or ARV, excluding patients who have received treatment and are being returned to their home or transported to another facility.

(2) In this regulation—

ARV means the business unit of Ambulance Service—Victoria known as Adult Retrieval Victoria;

PIPER means Paediatric Infant Perinatal Emergency Retrieval operated under the auspices of the Royal Children's Hospital.

Part 2—Transport of patients

Division 1—Classes of non-emergency patient transport service

9 Classes of non-emergency patient transport service

For the purposes of sections 7(2)(a)
and 13(2)(a) of the Act, the following classes of non-emergency patient transport service are prescribed—

(a) transport of low acuity patients;

(b) transport of medium acuity patients;

(c) transport of high acuity patients.

Division 2—Criteria for transportation

10 Criteria to be complied with before patient is transported

(1) A provider must not transport a patient if the patient's condition is time critical or is likely to become time critical during the transport.

1. 20 penalty units.

(2) A provider must not transport a patient if the patient's condition does not require monitoring during the transport.

1. 20 penalty units.

(3) A provider must not transport a patient if the patient has cardiac-related chest pain during the 2 hours immediately before the proposed transport.

1. 20 penalty units.

(4) A provider must not transport a patient unless, immediately before the transport—

(a) clinical observations appropriate to the patient's medical condition have been made and recorded; and

(b) the patient's acuity is assessed by—

(i) a registered medical practitioner; or

(ii) a registered nurse; or

Reg. 10
(4)(b)(iii) substituted by S.R. No. 148/2021 reg. 6(1).

(iii) a registered paramedic; and

(c) the patient is assessed by a person referred to in paragraph (b) as being haemodynamically stable for the duration of the transport.

1. 20 penalty units.

Reg. 10(5) amended by S.R. No. 148/2021 reg. 6(2).

(5) Despite anything to the contrary in this regulation, a patient may be transported in a vehicle if that course of action is recommended by any of the following persons working in the communications centre of Ambulance Service—Victoria as being necessary to avoid the possibility of the patient dying or suffering an adverse patient safety event were the patient required to wait for a different form of transport or for assessment—

(a) a registered medical practitioner;

(b) a registered nurse;

Reg. 10(5)(c) amended by S.R. No. 148/2021 reg. 6(3).

(c) a registered paramedic.

Division 3—Transporting patients

Reg. 11 substituted by S.R. No. 148/2021 reg. 7.

11 Transport of low acuity patients

(1) A provider must ensure that whenever a low acuity patient is transported in a stretcher vehicle—

(a) there are 2 crew members crewing the vehicle; and

(b) a suitably qualified and competent crew member travels in the patient compartment with the low acuity patient or patients for the duration of the transport.

Penalty: 20 penalty units.

(2) A provider must ensure that no more than 2 low acuity patients are transported at any one time in a vehicle that is equipped with a stretcher.

Penalty: 20 penalty units.

(3) This regulation does not apply to clinic transport service vehicles and hoist vehicles transporting low acuity patients.

12 Staffing and equipment of vehicles used for the transport of medium acuity patients

(1) When a medium acuity patient is transported, a provider must ensure that—

(a) a suitably qualified and competent crew member travels in the patient compartment with the medium acuity patient for the duration of the transport; and

(b) the medium acuity patient is not left unattended at any time while in the vehicle.

1. 20 penalty units.

(2) A provider must ensure that a medium acuity patient is transported in a vehicle that is equipped with a stretcher.

1. 20 penalty units.

   13 Staffing and equipment of vehicles used for the transport of high acuity patients

(1) When a high acuity patient is transported, a provider must ensure that—

(a) a suitably qualified and competent crew member travels in the patient compartment with the high acuity patient for the duration of the transport; and

(b) the high acuity patient is not left unattended at any time while in the vehicle.

1. 20 penalty units.

(2) A provider must ensure that a high acuity patient is transported in a vehicle that is equipped with a stretcher.

1. 20 penalty units.

Reg. 14 substituted by S.R. No. 148/2021 reg. 8.

14 High acuity or medium acuity patient must not be transported with another patient

A provider must ensure that a high acuity patient or a medium acuity patient is not transported with another patient in the same vehicle.

Penalty: 20 penalty units.

Division 4—Requirements applicable to all patients

15 Restriction on transport of patients

A provider must ensure that a patient is not transported with another patient in the same vehicle if either of those patients—

(a) is behaving in a way that may distress or endanger the other patient; or

(b) is immuno-suppressed; or

(c) has a condition that is likely to cause offence or distress to the other patient; or

(d) is at a high risk of dying during transport; or

(e) has or is suspected of having an infectious disease that has a high risk of being transmitted to the other patient; or

(f) reasonably requires privacy due to the patient's medical condition; or

(g) requires the use of therapeutic or monitoring devices that would prevent or inhibit ready access to each patient.

1. 20 penalty units.

   16 Handover notes and other documents

A crew member of a vehicle that is to be used to transport a patient from a medical service must, before the patient is transported, request the medical service to provide—

(a) handover notes in relation to the patient; and

(b) a copy of any advance care directive of the patient and any not for resuscitation request made by the patient.

17 When clinical advice must be obtained before loading a patient

(1) Before loading a patient into a vehicle, a crew member of the vehicle may request clinical advice from the provider if the crew member reasonably believes that—

(a) the vehicle used to transport the patient is not staffed by persons with skills, competencies and knowledge appropriate for ensuring that the patient's clinical needs are met for the duration of the transport; or

(b) the vehicle is not suitably equipped to enable the crew members to manage the patient's clinical needs for the duration of the transport.

(2) A provider must take reasonable steps to ensure that, when a crew member makes a request under subregulation (1), clinical advice is provided by—

(a) a registered medical practitioner; or

(b) a registered nurse; or

Reg. 17(2)(c) substituted by S.R. No. 148/2021 reg. 9.

(c) a registered paramedic; or

(d) a clinical instructor employed by the provider.

1. 20 penalty units.

(3) A provider must ensure that an audio recording is made of each oral request for clinical advice made under subregulation (1).

1. 20 penalty units.

(4) A provider must retain the audio recording referred to in subregulation (3) for a period of not less than 7 years after it is made.

1. 20 penalty units.

   18 Carers accompanying patients

Nothing in these Regulations prevents a carer of a patient accompanying the patient while the patient is being transported.

Part 3—Staffing of non-emergency patient transport services

19 Competencies for staff of non-emergency patient transport services

(1) A provider must ensure that any vehicle used to transport a patient is staffed by persons with skills, competencies and knowledge appropriate for ensuring that the patient's clinical needs can be met for the duration of the transport.

1. 20 penalty units.

Reg. 19(2) amended by S.R. No. 148/2021 reg. 10(1).

(2) Despite subregulation (1), a patient may be transported in a vehicle if that course of action is recommended by any of the following persons working in the communications centre of Ambulance Service—Victoria as being necessary to avoid the possibility of the patient dying or suffering an adverse patient safety event were the patient required to wait for a different form of transport or for assessment—

(a) a registered medical practitioner;

(b) a registered nurse;

Reg. 19(2)(c) amended by S.R. No. 148/2021 reg. 10(2).

(c) a registered paramedic.

(3) A provider must not employ a person as a clinical instructor unless the person has obtained at a minimum a certificate level IV Training and Assessment qualification or a qualification that, in the opinion of the Secretary, is equivalent to the first-mentioned qualification and—

(a) is a registered medical practitioner; or

(b) was employed by a non-emergency patient transport service as a clinical instructor immediately before 20 April 2016; or

Reg. 19(3)(c) amended by S.R. No. 148/2021 reg. 10(3).

(c) is a registered paramedic employed by an ambulance service who has worked for a period of not less than 18 months full time (or part time for not less than the equivalent of that period); or

(d) is employed by a non-emergency patient transport service and has at least 18 months full time (or part time for not less than the equivalent of that period) experience in transporting patients of all acuity levels and that person holds a degree or a diploma approved by the Secretary.

1. 20 penalty units.

(4) A provider must ensure that an Ambulance Transport Attendant employed by the provider to crew a vehicle for the purposes of patient transport—

(a) has at least 400 hours of supervised on road clinical practice experience over a period not exceeding 2 years; or

(b) is supervised by a person described in paragraph (a).

1. 20 penalty units.

Reg. 19(5) inserted by S.R. No. 148/2021 reg. 10(4).

(5) A provider must ensure that any patient transport officer who crews a vehicle that is providing a non-emergency patient transport service operated by the provider—

(a) has at least 100 hours of on road clinical practice experience in active patient care; or

(b) is supervised by an ambulance transport attendant or a person to whom subregulation (4)(a) applies.

Penalty: 20 penalty units.

Reg. 19(6) inserted by S.R. No. 148/2021 reg. 10(4).

(6) A provider must ensure that any staff member of the provider who drives a vehicle that is providing a non-emergency patient transport service operated by the provider has a full driver licence.

Penalty: 20 penalty units.

Reg. 19(7) inserted by S.R. No. 148/2021 reg. 10(4).

(7) In this regulation—

clinical practice experience in active patient care includes no more than 50% of clinical placement hours that involve active patient management and do not include observational shifts.

Reg. 20 amended by S.R. No. 148/2021 reg. 11(1)(2) (ILA s. 39B(2)).

20 Assessment of competency

(1) A provider must ensure that the competency of all staff referred to in regulation 19 is maintained at a satisfactory level throughout the course of their service as a staff member with the provider.

1. 20 penalty units.

Reg. 20(2) inserted by S.R. No. 148/2021 reg. 11(2).

(2) A provider must ensure that the competency of a staff member after receiving training for the purpose of subregulation (1) is recorded and attested to by the person who did the training.

Penalty: 20 penalty units.

Reg. 20(3) inserted by S.R. No. 148/2021 reg. 11(2).

(3) A provider must keep the record and attestation referred to in subregulation (2) available for production to an authorised officer under section 48 of the Act.

Penalty: 20 penalty units.

21 Skills maintenance training

(1) A provider must ensure that all staff referred to in regulation 19 are provided with annual training that is appropriate having regard to the nature of their work and that is in the following areas—

(a) basic life support;

(b) occupational health and safety, with particular attention to manual handling and infection control;

Reg. 21(1)(c) amended by S.R. No. 148/2021 reg. 12(1).

(c) current evidence-based clinical practice;

Reg. 21(1)(d) inserted by S.R. No. 148/2021 reg. 12(2).

(d) mental health training.

1. 20 penalty units.

(2) In addition to the requirements of subregulation (1), a provider must ensure that each crew member employed by the non‑emergency patient transport service who attends to medium acuity patients or high acuity patients is provided with training in defibrillator operation and electrocardiogram interpretation.

1. 20 penalty units.

(3) A provider must keep a record of—

(a) the names of staff who have participated in training in respect of each area set out in subregulations (1) and (2); and

(b) the level of accreditation achieved by each member of staff.

1. 10 penalty units.

   22 Staff identification

A provider must ensure that each member of staff referred to in regulation 19 wears an identification tag while on duty that shows—

(a) the member of staff's name and position; and

(b) the trading name of the provider.

1. 15 penalty units.

Part 4—Licensing

Division 1—Applications

23 Application for approval in principle

(1) For the purposes of section 8(2)(a) of the Act, the prescribed form is the form set out in Schedule 1.

(2) For the purposes of section 8(2)(b) of the Act, the prescribed fee is 124 fee units.

24 Application for variation or transfer of approval in principle

(1) The prescribed form of application for variation of transfer of an approval in principle under section 12(1) of the Act is the form set out in Schedule 2.

(2) For the purposes of section 8(2)(b) of the Act, the prescribed fee for variation of transfer of an approval in principle under section 12(1) of the Act is 42 fee units.

25 Application for a non-emergency patient transport service licence

(1) For the purposes of section 14(2)(a) of the Act, the prescribed form is the form set out in Schedule 3.

(2) For the purposes of section 14(2)(b) of the Act, the prescribed fee is 186 fee units.

(3) Without limiting section 14(3) of the Act, a person applying for a licence under section 14(1) of the Act must submit with the application—

(a) a certificate certifying that the applicant's quality assurance plan has been accredited by an accreditation body; or

Reg. 25(3)(b) amended by S.R. No. 148/2021 reg. 13(1).

(b) a draft quality assurance plan in accordance with regulation 29(1) and (2) and a report from an accreditation body that sets out the steps that a person must take for the quality assurance plan to be accredited by that body within 3 months after the person is granted a licence.

Reg. 25(4) inserted by S.R. No. 148/2021 reg. 13(2).

(4) Without limiting section 14(3) of the Act and subject to regulation 26(2), a person applying for a licence under section 14(1) of the Act must submit with the application a certificate of accreditation of the provider's occupational health and safety plan.

Reg. 26 amended by S.R. No. 148/2021 reg. 14 (ILA s. 39B(2)).

26 Conditions on licences

(1) For the purposes of section 17(1)(a) of the Act, a non-emergency patient transport service licence granted to an applicant who does not have a current certificate of quality accreditation from an accreditation body is subject to the condition that the licence holder must, within 3 months after being granted the licence—

(a) obtain a certificate of quality accreditation; and

(b) submit a copy of the certificate to the Secretary.

Reg. 26(2) inserted by S.R. No. 148/2021 reg. 14.

(2) For the purposes of section 17(1)(a) of the Act, a non-emergency patient transport service licence granted to an applicant who does not have a current certificate of accreditation of its occupational health and safety plan at the time the licence is granted is subject to the condition that the licence holder must, within 3 months after being granted the licence—

(a) obtain a certificate of accreditation of its occupational health and safety plan; and

(b) submit a copy of the certificate to the Secretary.

27 Application to renew a licence

(1) For the purposes of section 21(2)(a) of the Act, the prescribed form is the form set out in Schedule 4.

(2) For the purposes of section 21(2)(b) of the Act, the prescribed fee is—

(a) 137 fee units for up to and including 9 vehicles;

(b) 284 fee units for 10 to 49 vehicles;

(c) 431 fee units for 50 or more vehicles.

Reg. 27A inserted by S.R. No. 148/2021 reg. 15.

27A Application to transfer a licence

(1) For the purposes of section 23A of the Act, the form for an application to transfer a licence is the form set out in Schedule 4A.

(2) For the purposes of section 23A(2)(b) of the Act, the prescribed fee is 49 fee units.

28 Application to vary a licence

(1) For the purposes of section 26(2)(a) of the Act, the prescribed form is the form set out in Schedule 5.

(2) For the purposes of section 26(2)(b) of the Act, the prescribed fee is 49 fee units.

Division 2—Quality assurance plans

Reg. 29 (Heading) amended by S.R. No. 148/2021 reg. 16(1).

29 Development, contents and accreditation of quality assurance plan

(1) A person who applies for a licence under section 14(3) of the Act must develop a quality assurance plan which complies with subregulation (2).

(2) A quality assurance plan must include provisions in relation to the following matters—

(a) infection control;

(b) active clinical monitoring of patients;

(c) management of critical incidents;

(d) management of deteriorating patients;

(e) staff qualifications and training, assessment of qualifications and maintenance of the currency of qualifications;

(f) staff competencies and their maintenance and assessment by a registered training organisation;

(g) recognition of prior learning and overseas qualifications of staff providing clinical care and advice;

(h) access to clinical advice for crew members;

(i) drug security, including storage, use, disposal and records;

(j) manual handling of patients;

(k) patient records;

(l) transportation of personal belongings, including mobility devices;

(m) complaints management;

(n) clinical handover processes;

(o) vehicle equipment;

(p) vehicle crewing;

(q) vehicle and equipment maintenance;

(r) records of all maintenance and repairs to vehicles and equipment;

(s) vehicle and equipment cleaning;

(t) complaints register;

(u) process for investigating complaints.

Reg. 29(3) inserted by S.R. No. 148/2021 reg. 16(2).

(3) A quality assurance plan must be accredited by an accreditation body.

Reg. 30 amended by S.R. No. 148/2021 reg. 17.

30 Compliance with quality assurance plan

A licence holder must maintain and comply
with a quality assurance plan that complies with regulation 29(2) and (3).

31 Audit of quality assurance plan

(1) Subject to subregulation (2), if at any time during the duration of the licence the quality assurance plan of the licence holder is audited by an accreditation body, the licence holder must submit a copy of the audit report to the Secretary no later than 14 days after the licence holder receives a copy of the report from the accreditation body.

1. 15 penalty units.

(2) If an audit report referred to in subregulation (1) contains a notification as to the existence of a risk of a high probability of harm or injury to a patient, the licence holder must report that risk to the Secretary no later than 24 hours after the licence holder receives a copy of the report from the accreditation body.

1. 20 penalty units.

Reg. 32 (Heading) amended by S.R. No. 148/2021 reg. 18(1).

32 Revocation, suspension or expiry of accreditation of quality assurance plan

Reg. 32(1) amended by S.R. No. 148/2021 reg. 18(2).

(1) A licence holder must not operate a non‑emergency patient transport service if the accreditation of the licence holder's quality assurance plan is revoked or suspended or has expired.

1. 20 penalty units.

Reg. 32(2) amended by S.R. No. 148/2021 reg. 18(3).

(2) A licence holder must report immediately to the Secretary any suspension or revocation of the accreditation of the licence holder's quality assurance plan.

Pt 4 Div. 2A (Heading and regs 32A–32D) inserted by S.R. No. 148/2021 reg. 19.

Division 2A—Occupational health and safety plan

Reg. 32A inserted by S.R. No. 148/2021 reg. 19.

32A Development and contents of occupational health and safety plans

(1) A person who applies for a licence under section 14(1) of the Act must develop an occupational health and safety plan which complies with subregulation (2).

(2) An occupational health and safety plan must include provisions in relation to the following matters—

(a) the maintenance of a hazard register;

(b) incident reporting and management;

(c) risk evaluation;

(d) staff safety when manually handling patients;

(e) recording of incidents and resulting actions.

(3) An occupational health and safety plan must include copies of the current safety data sheets required to be kept under the Occupational Health and Safety Regulations 2017[5] in relation to hazardous chemicals used in the operation of the non‑emergency patient transport service.

(4) An occupational health and safety plan must be accredited by an accreditation body.

Reg. 32B inserted by S.R. No. 148/2021 reg. 19.

32B Compliance with occupational health and safety plan

A licence holder must maintain and comply with an occupational health and safety plan that complies with regulation 32A(2) and (3).

Reg. 32C inserted by S.R. No. 148/2021 reg. 19.

32C Audit of occupational health and safety plan

(1) If at any time during the duration of the licence the occupational health and safety plan of the licence holder is audited by an accreditation body, the licence holder must submit a copy of the audit report to the Secretary no later than 14 days after the licence holder receives a copy of the report from the accreditation body.

Penalty: 15 penalty units.

(2) If an audit report referred to in subregulation (1) contains a notification as to the existence of a risk of a high probability of harm or injury to a patient or a staff member, the licence holder must report that risk to the Secretary no later than 24 hours after the licence holder receives a copy of the report from the accreditation body.

Penalty: 20 penalty units.

Reg. 32D inserted by S.R. No. 148/2021 reg. 19.

32D Revocation, suspension or expiry of occupational health and safety plan

(1) A licence holder must not operate a non‑emergency patient transport service if the accreditation of the occupational health and safety plan of the licence holder is revoked or suspended or has expired.

Penalty: 20 penalty units.

(2) A licence holder must report immediately to the Secretary any suspension or revocation of the accreditation of the licence holder's occupational health and safety plan.

Division 3—Other matters during course of licence

Reg. 33 amended by S.R. No. 148/2021 reg. 20.

33 Critical incidents

A licence holder must report any sentinel event involving a patient to the Secretary within 24 hours after its occurrence.

34 Annual report

(1) A licence holder must, no later than 2 months after the end of each financial year, submit to the Secretary an annual report on the operation of the business of the non-emergency patient service during the previous financial year.

(2) An annual report must contain the following information in respect of the financial year reported on—

(a) the number of patients transported;

(b) the number of patients of each acuity level transported;

(c) particulars of any incident involving a patient suffering cardiac arrest while under the care of the licence holder;

(d) particulars of any transportation of a patient with a mechanical circulatory assist device;

Reg. 34(2)(e) amended by S.R. No. 148/2021 reg. 21.

(e) particulars of the occurrence of any adverse patient safety event in relation to a patient while under the care of the licence holder;

(f) any other information that the Secretary has, by notice given to the licence holder, requested the licence holder to include.

Pt 5 (Heading and regs 35, 36) substituted as Pt 5 (Heading and regs 35–36B) by S.R. No. 148/2021 reg. 22.

Part 5—Clinical governance

Reg. 35 substituted by S.R. No. 148/2021 reg. 22.

35 Clinical oversight committee

(1) A licence holder must establish and maintain a clinical oversight committee.

(2) The clinical oversight committee must have at least—

(a) one member who is a representative of the management of the licence holder; and

(b) one member who is a registered paramedic, if the licence holder employs registered paramedics as part of providing the service; and

(c) one member who is a registered nurse, if the licence holder employs registered nurses as part of providing the service; and

(d) one member who is a registered health practitioner, if the licence holder does not employ a registered paramedic or a registered nurse as part of providing the service.

Reg. 36 substituted by S.R. No. 148/2021 reg. 22.

36 Responsibilities of committee

The clinical oversight committee has the following responsibilities in relation to the service provided by the licence holder—

(a) reviewing each sentinel event;

(b) oversight of the process of transporting a patient to a hospital or medical facility to receive care that cannot be provided on site;

(c) overseeing processes to set the scope of practice of the service to ensure it does not provide services beyond its competencies and ability;

(d) overseeing processes to set the scope of clinical practice of all clinical staff;

(e) reviewing the clinical practice protocols, processes and operating procedures of the service;

(f) overseeing the verification of the credentials of all registered medical practitioners engaged by the service in any capacity—

(i) when their engagement commences; and

(ii) subsequently every 3 years;

(g) overseeing the auditing of patient care records and reviewing all measures taken as a result of reviews of those records;

(h) keeping any staff survey data and reviewing all measures taken as a result of reviews of those surveys;

(i) reviewing all complaints that relate to the experience of patients of the service;

(j) overseeing processes to continually assess the capacity of the service to provide safe patient-centred care.

Reg. 36A inserted by S.R. No. 148/2021 reg. 22.

36A Meetings of committee

(1) The clinical oversight committee must meet at least once in each 3 month period.

(2) The clinical oversight committee must maintain records of its meetings including its decisions and the reasons for its decisions.

Reg. 36B inserted by S.R. No. 148/2021 reg. 22.

36B Staff surveys

(1) A licence holder must conduct a staff survey at least once a year.

(2) The primary purpose of a staff survey is to ascertain the views of staff on staff and patient safety.

Part 6—Records

37 Records to be kept

(1) A provider must ensure that patient care records are maintained in accordance with regulation 38.

1. 15 penalty units.

(2) A provider must ensure that staff records are maintained in accordance with regulation 39.

1. 15 penalty units.

   38 Patient care records

(1) A patient care record in relation to a low acuity patient must include the following information—

(a) the patient's name;

(b) the patient's address;

(c) the patient's date of birth;

(d) the patient's gender;

(e) the time and date of the patient's transport and, in the case of aeromedical services, the flight time;

(f) the reason for the patient's transport;

(g) the patient's pick up location and final destination;

Reg. 38(1)(ga) inserted by S.R. No. 148/2021 reg. 23(1).

(ga) details of any monitoring or treatment provided to the patient during transportation;

(h) the names and titles of the crew members undertaking the patient's transport.

(2) If a low acuity patient's destination is a medical service or aged care service, the provider must ensure that the information contained in the patient care record is orally communicated to the person receiving the patient.

(3) A patient care record in relation to a medium acuity patient or a high acuity patient must include the following information—

(a) the patient's name;

(b) the patient's address;

(c) the patient's date of birth;

(d) the patient's gender;

(e) whether the patient is a medium acuity patient or a high acuity patient;

(f) all relevant clinical details of the patient including any co-morbidities;

(g) the time and date of the patient's transport and, in the case of an aeromedical service, the flight time;

(h) the reason for the patient's transport;

(i) the name and position of the person who assessed the patient as being haemodynamically stable for the duration of the transport;

(j) the patient's pick up location and final destination;

(k) details of any monitoring or treatment provided to the patient during transportation;

(l) the names and titles of the crew members undertaking the patient's transport.

(4) If a medium acuity patient or a high acuity patient's destination is a medical service or aged care service, the provider must ensure that—

(a) the information contained in the patient care record is communicated orally to the person receiving the patient; and

(b) a copy of the patient care record is provided to the person receiving the patient.

Reg. 38(5) inserted by S.R. No. 148/2021 reg. 23(2).

(5) The provider must ensure that at least 50 per cent of patient care records for medium or high acuity patients are reviewed to determine if there are any clinical issues or issues relating to patient safety.

39 Staff records

(1) Staff records must include the following information in relation to each crew member—

(a) full name;

(b) date of birth;

(c) job classification;

(d) qualifications;

(e) relevant clinical experience;

(f) if registered with a professional body, the relevant registration number;

(g) immunisation records as recommended in the infection control guidelines;

(h) mandatory skills maintenance training and accreditation record.

(2) For an aeromedical service, in addition to the information specified in subregulation (1), staff records must contain details of a pre-employment examination by a CASA appointed designated aviation medical examiner who is not a member of staff of the same aeromedical service as the crew member who is examined.

(3) A provider must retain the staff records in relation to a crew member for a period of not less than 2 years following the cessation of employment of the crew member.

1. 15 penalty units.

   40 Records of an aeromedical service

A provider of an aeromedical service must produce to the Secretary a copy of its current Air Operator's Certificate issued by CASA when applying for a licence or the renewal of a licence under the Act.

1. 15 penalty units.

Part 7—Patient rights and information

41 Establishment of complaints register

(1) A provider must establish a complaints register for all complaints received about the service, whether the complaints were made in writing or orally.

1. 10 penalty units.

(2) A provider must ensure that its complaints register contains the following information in relation to each complaint made—

(a) the name of the patient;

(b) the patient's pick up location and final destination;

(c) the nature of the complaint;

(d) the date of the complaint;

(e) details of any investigation of the complaint;

(f) the outcome of any investigation of the complaint;

(g) details of any action taken.

1. 10 penalty units.

   42 Investigation of complaints

A provider must ensure that any investigation of a complaint is carried out in a manner that is not detrimental to—

(a) the complainant; or

(b) the continued provision of services.

1. 10 penalty units.

   43 Contact details of a provider

A provider must ensure that contact details for its non-emergency patient transport service are provided to each patient transported by the service, before the completion of the transport.

1. 10 penalty units.

   44 Provision of information brochure

A provider must ensure that an information brochure containing the information set out in regulation 45 is made available on request to a patient who is or has been, or is about to be, transported by the service.

1. 10 penalty units.

   45 Content of information brochure

An information brochure provided to a patient in accordance with regulation 44 must contain the following information—

(a) the patient's rights when using a non‑emergency patient transport service;

(b) the non-emergency patient transport service's complaints procedure, including—

(i) contact details of the non-emergency patient transport service; and

(ii) how complaints about the service are managed and what the time frames for resolution are; and

(iii) other bodies to which a complaint about the service may be made.

Part 8—Infection control

46 Infection control management plan

(1) A provider must ensure that an infection control management plan is developed in compliance with the infection control guidelines.

1. 20 penalty units.

(2) Without limiting subregulation (1), the plan must—

(a) identify all possible areas where there is a risk of transmission of infection and the actions to be taken to control any such risk; and

(b) identify the steps to be followed if any action referred to in paragraph (a) is not taken; and

(c) identify those aspects of the service provided that require ongoing infection control; and

(d) identify the type of education to be provided to staff involved in the provision of clinical care to patients or the cleaning of a vehicle; and

(e) state the name and qualifications of the person responsible for identifying areas of risk; and

(f) identify the mechanism by which compliance with the infection control management plan will be monitored; and

(g) set out a process for the use, disposal and laundering of linen; and

(h) include the vehicle-cleaning plan developed under regulation 47(2).

(3) A provider must ensure that the infection control management plan is reviewed annually.

1. 20 penalty units.

   47 Vehicles

(1) If a vehicle modification results in a change of vehicle category code of a vehicle, a provider must ensure that the vehicle is not used to transport patients on a public road unless the provider has provided the Secretary with—

(a) a copy of the vehicle assessment signatory scheme approval certificate; or

(b) a photograph of the second stage of manufacture compliance plate.

1. 20 penalty units.

(2) A provider must ensure that a vehicle-cleaning plan is developed that complies with—

(a) the infection control guidelines; and

(b) subregulation (3).

1. 20 penalty units.

(3) The vehicle-cleaning plan must include—

(a) a cleaning schedule; and

(b) guidelines on cleaning practices.

(4) A provider must ensure that all vehicles used for the transport of patients by the non-emergency patient transport service are kept in a clean and hygienic condition.

1. 20 penalty units.

(5) A provider must ensure that all vehicles used for the transport of patients on a public road by the non-emergency patient transport service are equipped with warning lights that can be activated when at any incident attended by the vehicle.

1. 20 penalty units.

(6) In this regulation—

vehicle category code has the same meaning as it has in the relevant design rules within the meaning of the Road Safety (Vehicles) Regulations 2009[6].

Part 9—Provision, inspection and maintenance of vehicles and equipment

Reg. 48 amended by S.R. No. 148/2021 reg. 24 (ILA s. 39B(2)).

48 Maintenance of vehicles and equipment

(1) A provider must ensure that an annual maintenance schedule is developed to ensure all vehicles and equipment used in the course of transporting patients are kept in good working order at all times in accordance with the manufacturers' specifications.

1. 10 penalty units.

Reg. 48(2) inserted by S.R. No. 148/2021 reg. 24.

(2) The provider must ensure that if a vehicle is used to provide the non-emergency patient transport service—

(a) the vehicle is examined and tested by a licensed tester annually once the vehicle has reached a mileage of 200 000 km or three years of age, whichever is the sooner in accordance with Part 6 of the Road Safety (Vehicles) Regulations 2021; and

(b) a certificate of roadworthiness is issued in respect of the vehicle by the licensed tester testing the vehicle.

49 Records of maintenance

(1) A provider must keep an accurate record of all maintenance and repairs to vehicles and equipment used in the course of transporting patients.

1. 10 penalty units.

(2) A provider must ensure that the record referred to in subregulation (1) is retained and maintained for the lifespan of the vehicle or equipment to which it relates.

1. 10 penalty units.

Reg. 49A inserted by S.R. No. 148/2021 reg. 25.

49A Mileage of vehicle

A provider must not use a vehicle for non‑emergency patient transport if the mileage of the vehicle exceeds 400 000 km.

Penalty: 20 penalty units.

Reg. 49B inserted by S.R. No. 148/2021 reg. 25.

49B Exemption from vehicle mileage limit

(1) A provider may apply to the Secretary in respect of a vehicle used for non-emergency patient transport for an extension to the mileage of 400 000 km limit up to a maximum mileage of 600 000 km.

(2) On application under subregulation (1), the Secretary may grant an exemption in respect of a vehicle for the vehicle to be used for non-emergency patient transport up to a maximum mileage of 600 000 km.

(3) The Secretary must not grant an exemption under subregulation (2) unless the Secretary is satisfied that it is safe to do so.

(4) When granting an exemption, the Secretary may impose conditions on the exemption.

(5) A provider who has applied for an exemption under subregulation (1) must not use the vehicle for patient transport at any time after the vehicle exceeds a mileage of 400 000 km, unless an exemption has been granted.

(6) The provider of a vehicle that is granted an exemption must comply with the conditions imposed under subregulation (4).

Penalty: 20 penalty units.

50 Interiors of road vehicles

(1) This regulation applies in relation to vehicles used to transport patients on public roads by a non-emergency patient transport service.

(2) A provider must ensure that within each vehicle there is sufficient room between stretchers and seats to facilitate proper patient care and clinical monitoring.

1. 10 penalty units.

Reg. 50(2A) inserted by S.R. No. 148/2021 reg. 26(1).

(2A) The provider must ensure that each vehicle that contains 2 stretchers has a minimum separation of 350 mm between the stretchers.

Penalty: 10 penalty units.

(3) A provider must ensure that within each vehicle there is seating in the patient compartment for each attendant who travels in that compartment and seating for all other persons travelling in the vehicle.

1. 10 penalty units.

(4) A provider must ensure that each vehicle interior allows the patient to be viewed at all times by crew members.

1. 5 penalty units.

(5) A provider must ensure that each vehicle interior has sufficient heating and air-conditioning to ensure patient comfort within the vehicle.

1. 5 penalty units.

(6) A provider must ensure that each vehicle is provided with windows fitted to all doors.

1. 5 penalty units.

(7) A provider must ensure that windows fitted to the vehicle are tinted to a degree that is—

(a) sufficient to maintain patient privacy; and

Reg. 50(7)(b) amended by S.R. No. 148/2021 reg. 26(2).

(b) compliant with the Vehicle Standards contained in Schedule 1 to the Road Safety (Vehicles) Regulations 2021.

1. 5 penalty units.

(8) A provider must ensure that vehicle interiors are provided with adequate interior lighting to provide safe patient care at all times within all areas of the vehicle and that the lighting can be adjusted from the patient compartment and from the driver compartment.

1. 10 penalty units.

Reg. 50(9) amended by S.R. No. 148/2021 reg. 26(2A).

(9) A provider must ensure that vehicle interiors are provided with smooth, impermeable and seamless materials for the surface of floors and walls.

1. 5 penalty units.

(10) A provider must ensure that the vehicle is able to accommodate and restrain any mobility device that a patient takes into the vehicle.

1. 10 penalty units.

Reg. 50(11) inserted by S.R. No. 148/2021 reg. 26(3).

(11) The interior of a vehicle must be maintained and kept in good repair at all times.

Penalty: 10 penalty units.

Reg. 50(12) inserted by S.R. No. 148/2021 reg. 26(3).

(12) The patient compartment of the vehicle must be checked and serviced at the times specified in subregulation (13) to ensure that—

(a) all fixtures and fittings are tightly fixed to the vehicle; and

(b) all compartment wall and floor surfaces are undamaged.

Penalty: 20 penalty units.

Reg. 50(13) inserted by S.R. No. 148/2021 reg. 26(3).

(13) For the purposes of subregulation (12), the vehicle must be checked and serviced at the following times—

(a) when the vehicle reaches a mileage of 200 000 km;

(b) when the vehicle reaches a mileage of 400 000 km;

(c) in the case of a vehicle that has been granted an exemption under regulation 49B(2) to be used after reaching a mileage of 400 000 km, annually after the vehicle reaches that limit, until the vehicle reaches a mileage of 600 000 km or ceases to be in use (whichever is the earlier).

Reg. 51 amended by S.R. No. 148/2021 reg. 27(1)(2) (ILA s. 39B(2)).

51 Equipment

(1) A provider must ensure that any vehicle used to transport a patient carries all the equipment and supplies necessary to meet the patient's clinical needs for the duration of the transport, including an Automated External Defibrillator, portable oxygen, suction and a bag valve mask.

1. 20 penalty units.

Reg. 51(2) inserted by S.R. No. 148/2021 reg. 27(2).

(2) A provider must ensure that all stretchers carried in vehicles are power lift stretchers.

Penalty: 20 penalty units.

Reg. 51(3) inserted by S.R. No. 148/2021 reg. 27(2).

(3) A provider must ensure that any vehicle equipped with a stretcher carries a lifting cushion at all times.

Penalty: 20 penalty units.

Reg. 51(4) inserted by S.R. No. 148/2021 reg. 27(2).

(4) Subregulation (2) does not apply to clinic transport service vehicles and hoist vehicles transporting low acuity patients.

52 Communication devices

A provider must ensure that communication devices are available at all times when a vehicle is used to transport a patient so as to maintain contact between the vehicle and the non‑emergency patient transport service base, the medical service destination and Ambulance Service—Victoria.

1. 20 penalty units.

Reg. 52A inserted by S.R. No. 148/2021 reg. 28.

52A Change to vehicle category code of vehicle

(1) If a vehicle modification results in a change of vehicle category code of a vehicle, a provider must ensure that the vehicle is not used to transport patients on a public road unless the provider has provided the Secretary with—

(a) a copy of the vehicle assessment signatory scheme approval certificate; or

(b) a photograph of the second stage of manufacture compliance plate.

Penalty: 20 penalty units.

(2) In this regulation—

vehicle category code has the same meaning as it has in the relevant Australian Design Rules within the meaning of the Road Safety (Vehicles) Regulations 2021.

Part 10—Insurance

Reg. 53 amended by S.R. No. 148/2021 reg. 29.

53 Public and professional liability insurance

A provider must obtain public liability insurance and professional indemnity insurance, each to the value of not less than $20 000 000.

Part 11—Aeromedical services

54 Report of breach of CASA requirements

A provider of an aeromedical service must report immediately to the Secretary if it is issued by CASA with—

(a) a non-compliance notice; or

(b) a show cause notice within the meaning of section 3 of the Civil Aviation Act 1988 of the Commonwealth.

1. 20 penalty units.

   55 Aircraft equipment

A provider of an aeromedical service must ensure that any aircraft it uses for the aeromedical service is fitted with—

(a) a 240 volt (2 amp) power supply with 2 outlets; and

(b) if the transport of incubators or other 12 volt devices is required, a 12 volt (10 amp) power supply compliant with any applicable electrical standards.

1. 20 penalty units.

   56 Configuration

(1) A provider of an aeromedical service must ensure that the clinical facilities and equipment in an aircraft used by it for the aeromedical service are placed in a position to allow continuous patient treatment, including during adverse weather conditions.

1. 10 penalty units.

(2) A provider of an aeromedical service must ensure that a seat is provided for each person travelling on the aircraft.

1. 10 penalty units.

   57 Stowage

(1) A provider of an aeromedical service must ensure that an aircraft used by it for the aeromedical service provides sufficient and appropriate storage space and restraint for any medical equipment carried on board.

1. 10 penalty units.

(2) A provider of an aeromedical service must ensure that an aircraft used by it for the aeromedical service is suitable for the carriage and stowage of passenger or patient cabin baggage and an additional 5 kilograms of luggage for each passenger.

1. 10 penalty units.

   58 Loading

(1) A provider of an aeromedical service must ensure that the main cabin door and stretcher loading system of an aircraft used by it for the aeromedical service are designed to permit boarding and disembarking of both ambulatory and stretcher patients.

1. 10 penalty units.

(2) A provider of an aeromedical service must ensure that loading and unloading a stretcher into and off an aircraft used by it for the aeromedical service requires not more than 2 persons.

1. 10 penalty units.

(3) A provider of an aeromedical service must ensure the stretcher-loading system of an aircraft used by it for the aeromedical service allows access to patients to be maintained at all times during patient loading and unloading.

1. 10 penalty units.

   59 Cabin

A provider of an aeromedical service must ensure, in respect of any aircraft used by it for an aeromedical service, that—

(a) the cabin lining and floor coverings are of a smooth, non-skid, anti-static, washable material, sealed against the aircraft sidewalls to window level; and

(b) adequate lighting is provided in the cabin to provide safe patient care at all times; and

(c) for night flights, opaque washable curtains or dividers are fitted between the cockpit and cabin.

1. 10 penalty units.

   60 Medical equipment

A provider of an aeromedical service must ensure that any aircraft used by it for the aeromedical service is fitted with—

(a) a CASA approved medical oxygen system capable of supplying adequate oxygen that—

(i) has a warning device or devices for indicating main medical oxygen supply exhaustion; and

(ii) enables oxygen to be turned off during flight; and

(b) a suction system capable of performing in all foreseeable cabin pressures that—

(i) has one suction outlet and apparatus for each stretcher and one reserve method of applying suction; and

(ii) is able to operate when the aircraft is not in flight.

1. 20 penalty units.

   61 Other equipment requirements

A provider of an aeromedical service must ensure that all patients dependent on a mechanical ventilator during non-emergency transport are protected with a disconnect alarm and have capnography available to them.

1. 20 penalty units.

Pt 12 (Heading and regs 62–64) inserted by S.R. No. 148/2021 reg. 30.

Part 12—Transitional provisions

Reg. 62 inserted by S.R. No. 148/2021 reg. 30.

62 Transitional provision—mileage

A provider is not required to comply with regulation 49A until 30 November 2026 in relation to a vehicle that was being used by the provider for the non-emergency patient transport service immediately before the commencement of the Non-Emergency Patient Transport Amendment Regulations 2021.

Reg. 63 inserted by S.R. No. 148/2021 reg. 30.

63 Transitional provision—minimum separation requirement

A provider is not required to comply with regulation 50(2A) until 30 November 2026 in relation to a vehicle that was being used by the provider for the non-emergency patient transport service immediately before the commencement of the Non-Emergency Patient Transport Amendment Regulations 2021.

Reg. 64 inserted by S.R. No. 148/2021 reg. 30.

64 Transitional provision—power lift stretchers and lifting cushions

(1) A provider is not required to comply with regulation 51(2) until 30 November 2024 in relation to a vehicle that was being used by the provider for the non-emergency patient transport service immediately before the commencement of the Non-Emergency Patient Transport Amendment Regulations 2021.

(2) A provider is not required to comply with regulation 51(3) until 30 November 2022 in relation to a vehicle that was being used by the provider for the non-emergency patient transport service immediately before the commencement of the Non-Emergency Patient Transport Amendment Regulations 2021.

Schedule 1—Application for approval in principle to operate a non-emergency patient transport service

Regulation 23(1)

Application for approval in principle to operate a non-emergency patient transport service

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

(4) If the applicant is a body corporate, the name and address of a director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

SECTION B

(1) The name (or proposed name) of the non-emergency patient transport service, its street address and the municipal district in which the service is, or is to be, located:

(2) This application is for an approval in principle for a non-emergency patient transport service intending to undertake—

• transport of low acuity patients;
• transport of medium acuity patients;
• transport of high acuity patients.

(3) The proposed number and types of vehicles:

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*Delete if inapplicable.

Sch. 2 substituted by S.R. No. 148/2021 reg. 31.

Schedule 2—Application for variation or transfer of certificate of approval in principle to operate a non-emergency patient transport service

Regulation 24(1)

Application for variation or transfer of certificate of approval in principle to operate a non-emergency patient transport service

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

SECTION B

(1) The name (or proposed name) of the non-emergency patient transport service, its street address and the municipal district in which the service is to be located:

(2) The number and type of vehicles (even if no changes are proposed):

(3) This application is for—

 variation of the certificate of approval in principle or any condition to which it is subject; or

 transfer of the certificate of approval in principle to another person.

(4) If the application relates to the variation of the certificate of approval in principle, the reason for the proposed variation:

(5) If the application relates to the transfer of the certificate of approval in principle to another person—

(a) the name of that person; and

(b) the postal address of that person; and

(c) that person's telephone number and email address.

(6) If the proposed transferee is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

Signature of applicant:

Name of each signatory:

Date:

*Delete if inapplicable.

Schedule 3—Application for a non‑emergency patient transport service licence

Regulation 25(1)

Application for a non‑emergency patient transport service licence

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

(4) If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

SECTION B

(1) The class of non-emergency patient transport for which a licence is sought—

• transport of low acuity patients;
• transport of medium acuity patients;
• transport of high acuity patients.

(2) The proposed name of the non-emergency patient transport service, its street address and the municipal district in which the service is located:

(3) The proposed number and types of vehicles:

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*Delete if inapplicable.

Schedule 4—Application for the renewal of a non-emergency patient transport service licence

Regulation 27(1)

Application for the renewal of
a non-emergency patient transport service licence

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

(4) If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

SECTION B

(1) The class of non-emergency patient transport for which a licence is sought—

• transport of low acuity patients;
• transport of medium acuity patients;
• transport of high acuity patients.

(2) The proposed name of the non-emergency patient transport service, its street address and the municipal district in which the service is located:

(3) The proposed number and types of vehicles:

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

Sch. 4A inserted by S.R. No. 148/2021 reg. 32.

Schedule 4A—Application for transfer of licence to operate a non-emergency patient transport service

Regulation 27A(1)

Application for transfer of Licence to operate a non-emergency patient transport service

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

SECTION B

(1) The name of the non-emergency patient transport service, its street address and the municipal district in which the service is to be located:

(2) The number and type of vehicles (even if no changes are proposed):

(3) In relation to the person to whom the licence is to be transferred

(a) the name of that person; and

(b) the postal address of that person; and

(c) that person's telephone number and email address.

(4) If the proposed transferee is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

Signature of applicant:

Name of each signatory:

Date:

Sch. 5 substituted by S.R. No. 148/2021 reg. 33.

Schedule 5—Application for variation of a non-emergency patient transport service licence

Regulation 28(1)

Application for variation of a non-emergency patient transport service licence

SECTION A

(1) Full name of applicant:

(2) Postal address of applicant:

(3) The name, telephone number and email address of a contact person for the purposes of the application:

SECTION B

(1) The nature of the variation sought (variation of licence or variation of condition to which licence is subject):

(2) Details of the variation sought, including the proposed acuity level:

(3) The number and type of vehicles (even if no changes are proposed):

(4) If regulation 52A(1) applies to the variation, attach—

(a) a copy of the vehicle assessment signatory scheme approval certificate; or

(b) a photograph of the second stage of manufacture compliance plate.

Signature of applicant:

Name of each signatory:

Date:

Sch. 6 revoked by S.R. No. 148/2021 reg. 34.

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Endnotes

1 General information

See www.legislation.vic.gov.au for Victorian Bills, Acts and current Versions of legislation and up-to-date legislative information.

The Non-Emergency Patient Transport Regulations 2016, S.R. No. 28/2016 were made on 19 April 2016 by the Governor in Council under section 64 of the Non-Emergency Patient Transport Act 2003, No. 69/2003 and came into operation on 20 April 2016: regulation 3.

The Non-Emergency Patient Transport Regulations 2016 will sunset 10 years after the day of making on 19 April 2026 (see section 5 of the Subordinate Legislation Act 1994).

INTERPRETATION OF LEGISLATION ACT 1984 (ILA)

Style changes

Section 54A of the ILA authorises the making of the style changes set out in Schedule 1 to that Act.

References to ILA s. 39B

Sidenotes which cite ILA s. 39B refer to section 39B of the ILA which provides that where an undivided regulation, rule or clause of a Schedule is amended by the insertion of one or more subregulations, subrules or subclauses the original regulation, rule or clause becomes subregulation, subrule or subclause (1) and is amended by the insertion of the expression "(1)" at the beginning of the original regulation, rule or clause.

Interpretation

As from 1 January 2001, amendments to section 36 of the ILA have the following effects:

• Headings

All headings included in a Statutory Rule which is made on or after
1 January 2001 form part of that Statutory Rule. Any heading inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
This includes headings to Parts, Divisions or Subdivisions in a Schedule; Orders; Parts into which an Order is divided; clauses; regulations; rules; items; tables; columns; examples; diagrams; notes or forms.
See section 36(1A)(2A)(2B).

• Examples, diagrams or notes

All examples, diagrams or notes included in a Statutory Rule which is made on or after 1 January 2001 form part of that Statutory Rule. Any examples, diagrams or notes inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, form part of that Statutory Rule. See section 36(3A).

• Punctuation

All punctuation included in a Statutory Rule which is made on or after
1 January 2001 forms part of that Statutory Rule. Any punctuation inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
See section 36(3B).

• Provision numbers

All provision numbers included in a Statutory Rule form part of that Statutory Rule, whether inserted in the Statutory Rule before, on or after
1 January 2001. Provision numbers include regulation numbers, rule numbers, subregulation numbers, subrule numbers, paragraphs and subparagraphs. See section 36(3C).

• Location of "legislative items"

A "legislative item" is a penalty, an example or a note. As from 13 October 2004, a legislative item relating to a provision of a Statutory Rule is taken to be at the foot of that provision even if it is preceded or followed by another legislative item that relates to that provision. For example, if a penalty at the foot of a provision is followed by a note, both of these legislative items will be regarded as being at the foot of that provision. See section 36B.

• Other material

Any explanatory memorandum, table of provisions, endnotes, index and other material printed after the Endnotes does not form part of a Statutory Rule. See section 36(3)(3D)(3E).

2 Table of Amendments

This publication incorporates amendments made to the Non-Emergency Patient Transport Regulations 2016 by statutory rules, subordinate instruments and Acts.

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Non-Emergency Patient Transport Amendment Regulations 2021, S.R. No. 148/2021

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

3 Amendments Not in Operation

This version does not contain amendments that are not yet in operation.

4 Explanatory details

1. Reg. 4(a): S.R. No. 135/2005 as amended by S.R. Nos 78/2010 and 117/2014, extended in operation by S.R. No. 126/2015 and amended by S.R. No. 151/2015. ↑

2. Reg. 4(b): S.R. No. 78/2010. ↑

3. Reg. 4(c): S.R. No. 117/2014. ↑

4. Reg. 5(1) def. of certificate of roadworthiness: S.R. No. 116/2021. ↑

5. Reg. 32A(3): S.R. No. 22/2017 as amended by S.R. Nos 71/2018, 176/2018, 71/2019, 84/2020, 106/2020, 141/2020, 8/2021, 88/2021, 112/2021 and 137/2021. ↑

6. Reg. 47(6): S.R. No. 118/2009. Reprint No. 2 as at 30 January 2015. Reprinted to S.R. No. 201/2014. Subsequently amended by S.R. Nos 79/2015, 118/2015 and 159/2015.

——

Fee Units

These Regulations provide for fees by reference to fee units within the meaning of the Monetary Units Act 2004.

The amount of the fee is to be calculated, in accordance with section 7 of that Act, by multiplying the number of fee units applicable by the value of a fee unit.

The value of a fee unit for the financial year commencing 1 July 2021 is $15.03. The amount of the calculated fee may be rounded to the nearest 10 cents.

The value of a fee unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004. The value of a fee unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.

Penalty Units

These Regulations provide for penalties by reference to penalty units within the meaning of section 110 of the Sentencing Act 1991. The amount of the penalty is to be calculated, in accordance with section 7 of the Monetary Units Act 2004, by multiplying the number of penalty units applicable by the value of a penalty unit.

The value of a penalty unit for the financial year commencing 1 July 2021 is $181.74.

The amount of the calculated penalty may be rounded to the nearest dollar.

The value of a penalty unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004. The value of a penalty unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.

——

Table of Applied, Adopted or Incorporated Matter

The following table of applied, adopted or incorporated matter was included in S.R. No. 28/2016 in accordance with the requirements of regulation 5 of the Subordinate Legislation Regulations 2014.

| **Statutory rule provision** | **Title of applied, adopted or incorporated document** | **Matter in applied, adopted or incorporated document** |
| --- | --- | --- |
| Regulation 5(1), definition of ***infection control guidelines*** | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2010 | The whole |
| Regulation 39(1)(g) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2010 | Part C, C2.2.3 Staff records |
| Regulation 46(1) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2010 | Part C, C1.3 Infection prevention and control program |
| Regulation 47(2) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2010 | Part B, B1.4 Routine management of the physical environment |
| **Statutory rule provision** | **Title of applied, adopted or incorporated document** | **Matter in applied, adopted or incorporated document** |
| --- | --- | --- |
| Regulation 50(9) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2010 | Part B, B1.4 Routine management of the physical environment and Part C, C6.2.3 Control of surface contamination through material selection |

——

Table of Applied, Adopted or Incorporated Matter

The following table of applied, adopted or incorporated matter was included in S.R. No. 148/2021 in accordance with the requirements of regulation 5 of the Subordinate Legislation Regulations 2014.

| **Statutory rule provision** | **Title of applied, adopted or incorporated document** | **Matter in applied, adopted or incorporated document** |
| --- | --- | --- |
| Regulation 5(1), definition of ***infection control guidelines*** | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2019 | The whole |
| Regulation 39(1)(g) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2019 | Section 4.2.1 |
| **Statutory rule provision** | **Title of applied, adopted or incorporated document** | **Matter in applied, adopted or incorporated document** |
| Regulation 46(1) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2019 | Section 3.1.3 |
| Regulation 47(2) | National Health and Medical Research Council's Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the Commonwealth in 2019 | Section 3.1.3 |

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