To establish the initial application process and procedure for approval of Advanced Life Support (ALS) service providers in the S-SV EMS Region. This does not apply to existing S-SV approved ALS service providers.

AUTHORITY:

California Health & Safety Code, Division 2.5, Sections 1797, et seq.

California Code of Regulations, Title 22, Division 9, Sections 100167, 100168, 100169, 100170 and 100171.

California Code of Regulation Title 13, Section 1100 et seq.

POLICY:

An ALS service provider shall meet all requirements set forth by State law, regulations and S-SV EMS Agency policy.

PROCEDURE:

1. All applicant agencies shall fully complete the "Advanced Life Support Service Provider Application For Approval" packet. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
   
   
2. Advanced Life Support Service Provider Application For Approval packet:
   
   Applicants shall submit the following information/ documentation in the following order:
   
   PREFACE
   
   0-1 Application Checkoff List - (Form # 89400-1)
   
   0-2 Statement of Fact - (Form # 89400-2)
   
   0-3 Statement of Good Faith - (Form # 89400-3)
   
   SECTION I - ORGANIZATION/BUSINESS INFORMATION:
   
   1-1 Application Face Sheet - (Form # 89401-1).
   
   1-2 Organization Chart.
   
   1-3 PUBLIC AGENCY - List of Chief of Department, EMS Coordinator, Medical Director (if applicable) - (Form # 89401-3A).
   
   PRIVATE SERVICE - List of Owners, Partners, Board of Directors, Chief Executive Officer, Medical Director (if applicable) - (Form # 89401-3B).
   
   1-4 Statement of Legal History - (Form # 89401-4).*
   
   1-5 Application For Criminal Record Check -(Form # 89401-5).*
   
   1-6 Description of service/intended service.
   
   1-7 Location of stations/substations - (Form # 89401-7).
   
   1-8 Copies of business license and county permit(s) for ambulance services, as applicable.
   
   *NOT APPLICABLE TO PUBLIC AGENCIES.
   
   1-9 A Letter of Intent or copy of an executed contract with an S-SV base hospital to provide base hospital service for your ALS service.
   
   (A copy of an executed agreement with an S-SV base hospital will be required prior to implementation of an ALS service.)
   
   1-10 Description and flow chart of complaint investigation procedure and resolution process related to: (a) billing, (b) personnel and (c) delivery of service.
   
   1-11 Three letters of reference in support of service.
   
   SECTION II - FISCAL INFORMATION:
   
   2-1 PRIVATE SERVICE - Provide the company's financial statement for the previous fiscal year, prepared by the company's auditor. (Financial information will remain confidential.)
   
   PUBLIC AGENCY - Provide copy of agency budget, including budget for ALS service.
   
   IF A SERVICE PROVIDER APPLICANT IS A NEWLY ESTABLISHED BUSINESS - attach a Business Financial Plan.
   
   2-2 Provide a statement regarding your service's policy on accepting or not accepting Medicare assignments, if applicable, or statement that you do not bill for service.
   
   2-3 Provide a list of rates charged for services, if applicable, or statement that you do not bill for service.
   
   SECTION III - INSURANCE:
   
   3-1 Proof of insurance coverage: Attach certificates or copies.
   
   If self-insured: Provide statement of self-insurance.
   
   SECTION IV - PERSONNEL:
   
   4-1 Provide name, current address, and certification/local accreditation and/or professional license number of all the following applicable employees:
   
   * Drivers and attendants - (Form # 89404-1A).
   
   * EMT-Paramedics - (Form # 89404-1B).
   
   * Licensed personnel, including; physicians, registered nurses and/or respiratory therapists. If EMS aircraft service provider, list pilots - (Form # 89404-1C).
   
   4-2 Describe staffing necessary for the number of units to be operated by the service.
   
   4-3 Describe, or attach policy, and provide an organization chart showing who is responsible for the supervision of EMT and ALS personnel. Provide description of supervisors duties and responsibilities.
   
   4-4 Describe how the service proposes that its personnel will comply with requirements for continuing education/training and periodic certification/ licensing.
   
   4-5 Describe or attach the employee orientation policy or program.
   
   4-6 Complete and attach Alcohol/Drug-Free Workplace Certification form - (Form # 89404-6).
   
   4-7 Attach policy related to providing an Alcohol/Drug-Free Workplace in accordance with Government Code, Section 8355.
   
   SECTION V - VEHICLES/EQUIPMENT/SUPPLIES:
   
   5-1 List of all service provider vehicles, including ambulances, which will be utilized in providing Advanced Life Support Services in the S-SV EMS region - (Form # 89405-1).
   
   5-2 Attach copies of ambulance license(s) issued by CHP, as applicable.
   
   5-3 Attach copies of any CHP vehicle inspection reports, unless exempt, include deficiencies found during the past year. If deficiencies were found, list corrective action taken.
   
   5-4 Description or policy of applicant's vehicle maintenance program.
   
   5-5 Description of communications and 24-hour dispatch capabilities, including recording of telephone and radio communications of the service, recording maintenance and retrieval system, recording of response times and the protocols used for dispatching service.
   
   5-6 Attach completed Vehicle Communication Equipment form - (Form # 89405-6).
   
   5-7 List of Biomedical equipment service contracts - and description of Biomedical equipment maintenance program.
   
   5-8 Attach statement that your service will comply with the S-SV ALS inventory requirements.
   
   5-9 Provide a description or policy of the service's plan for drug storage and resupply.
   
   5-10 Provide location of storage, supply or resupply of drugs, dangerous drugs and controlled substances.
   
   5-11 List name, current address and license number of the physician and/or clinical pharmacist, if the service warehouses drugs.
   
   SECTION VI - CONTINUOUS QUALITY IMPROVEMENT/QUALITY ASSURANCE AND MEDICAL RECORDS:
   
   6-1 Attach a copy of the service provider's internal quality assurance/improvement program. Include name(s) of responsible individual(s). (See California Code of Regulations, Title 22, Section 100167.)
   
   6-2 Provide a description and/or policy of how the service proposes to maintain medical records on the treatment of patients.
   
   6-3 Provide statement that the service will use the S-SV EMS Agency's scannable Patient Care Report (PCR) form on all responses and/or transports within and out of the S-SV EMS region. (See California Code of Regulations, Title 22, Section 100167.)
   
   Patient Care Report data shall be forwarded to the S-SV EMS Agency, at minimum, on a monthly basis.
   
   SECTION VII - INFECTION CONTROL AND BIO-HAZARDOUS MATERIALS:
   
   7-1 Describe or attach the service's plan for infection control and all applicable O.S.H.A. requirements.
   
   7-2 Describe or attach the service's plan for handling and disposal of bio-hazardous materials.
   
   
3. Application For Designation/Approval Process By S-SV EMS:

The ALS Service Provider Application For Designation/Approval process shall include all of the following:

• Perform initial review of all submitted application material for completeness.
  
  
• Perform background investigation of applicant service provider.
  
  
• Review application and proposed service for compliance with State law, regulations and S-SV EMS Agency requirements.
  
  
• Inspection by S-SV EMS Agency of ambulances, vehicles and station(s) to verify compliance with S-SV inventory and station requirements.
  
  
• Verify executed agreement with an S-SV approved base hospital.
  
  
• An executed ALS Service Provider Agreement with the S-SV EMS Agency.