"Service Records and Facilities Inspection Report - Emergency Medical Services" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH  EMERGENCY MEDICAL SERVICES
SERVICE RECORDS AND FACILITIES INSPECTION REPORT (SECTION 401.31, F.S.)
Service Name: ____________________________________________________________ Inspection Date: ______/_______/_____ Phone: (___)_____________________
County: ________________________ Type of Inspection:  Initial  Reinspection  Random  Complaint Announced  Unannounced
License Type: ______  Transport  Nontransport Date of Last Inspection: _______/_______/_______ License Expiration Date: _______/_______/________
Inspection Codes:
Rating Categories:
1 = Item meets inspection criteria.
1 = Lifesaving equipment, medical supplies, drugs, records or procedures
1a = Item corrected during inspection to meet criteria.
2 = Intermediate support equipment, medical supplies, drugs, records or procedures
2 = Items not in compliance with inspection criteria.
3 = Minimal support equipment, medical supplies, records or procedures
I. ADMINISTRATIVE AND RECORDS STORAGE (Chapter 64J-1, F.A.C.)
1. Records storage and security.
4. Items are stored in a climate controlled (i.e. – heated and air conditioned) location.
2. Records storage for 5 years.
II. RECORDS (Section 401, F.S., Chapter 64J-1, F.A.C)
5. The area is clean and sanitary.
1. Current service license on display. (Chapter 64J-1, F.A.C)
B. Observe if the following requirements for controlled substances are being met:
2. Vehicle/Aircraft Records (Chapter 64J-1, F.A.C.) To Include:
1. The requirements listed in items 105 above are being met.
A. Registration.
2. Medical director has registered storage areas with DEA (Chapter 64J-1, F.A.C.)
B. Verification of vehicle permit.
C. Written operating procedures for the storage and handling of fluids and medications specify the
following:
3. Previous Inspection Forms, (Chapter 64J-1, F.A.C.)
1. Security procedures.
2. Items stored in a climate controlled location (i.e. – Heated and air conditioned)
4. Personnel Records for each EMT, paramedic (Chapter 64J-1, F.A.C.)
To Include:
A. Date of employment.
3. Deteriorated or expired items stored in a quarantine area, separate from usable items.
B. Record of training.
4. Inventory procedures.
C. Current professional certification.
D. Written operating procedures for the storage and handling of controlled substances specify the
following:
D. Documentation of completion of the 1988 D.O.T. Air Medical Crew
1. Storage procedures.
National Standard Curriculum-Advanced, for Paramedic Crew members
(Chapter 64J-1, F.A.C.)
5. Ambulance driver record (for each per Section 401.281(1), F.S.)
2. The positions that have access to controlled substances.
To include: Statements attesting to A.B.C.
A. 18 years old.
3. Shift change inventory procedures for vehicles.
B. Not addicted to alcohol or controlled substances.
4. Procedures to be used for the documentation of use, disposal of excess and resupply of
vehicles with controlled substances.
C. Free from physical or mental defect or disease that would impair
5. Procedures used for inventory discrepancies.
ability to drive.
D. Driving record verification.
F. Verify that the following occurs with regard in controlled substances:
E. Possess valid class “D” or chauffeur license.
1. Storage records are maintained on file at the location where he controlled substances are
stored.
F. Is trained in safe operation of emergency vehicle – 16 hour E.V.O.C.
2. All required inventories and records are maintained at least two years.
G. Possesses a valid American Red Cross First Aid and Personal
3. Records are maintained separately from other records.
Safety card or its equivalent.
H. Possesses a valid American Red Cross or American Heart
8. Equipment substitutions when authorization by medical director (Chapter 64J-1, F.A.C.)
Association CPR or ACLS card.
NOTE: Current EMT or paramedic certification is evidence of compliance with
9. Biomedical Waste operating procedures (Section 381.80, F.S. and Chapters 64J-1, F.A.C.) to
items A, B, C and G above. (Section 401.27(4), F.S.)
include:
6. Medical Director (Section 64J-1, F.A.C.)
A. Proper handling
A. Qualifications: Current ACLS certification or board certification in
B. Proper storage
emergency medicine (Chapter 64J-1, F.A.C.)
B. Duties and responsibilities (Chapter 64J-1, F.A.C.)
C. Proper disposal
1. Write/review operating procedures for patient care.
10. EMS providers disaster plan integrates both local and regional disaster plan (Chapter 64J-1,
F.A.C.)
2. Written quality assurance program operating procedures that require the
11. Adult and pediatric CID approval in writing by medical director (Chapter 64J-1, F.A.C.)
following:
a. Prompt review of run reports.
12. If an EMS provider maintains an air ambulance license or has permitted aircraft, the
following record requirements that apply (Section 401.251 F.S. and Chapter 64J-1, F.A.C.)
b. Direct observation of personnel.
A. Emergency protocol for overdue aircraft, when radio communications cannot be established,
or when aircraft cannot be located.
B. Documentation of flight done every 15 minutes while enroute to and from patient’s location.
3. Documentation of implementation of #2 above.
4. Documented of participation in direct contract time with EMS Field Level
C. Safety committee to include:
Providers for a minimum of 10 hours per year.
1. Membership of one pilot, one flight medical crew member, medical director, EQ
representative and one hospital administrator (if hospital based).
7. Inventory, storage and security procedures for medications, fluids and controlled
2. Written safety procedures.
substances (Sections 499, 893, F.S., and Chapters 64J-1, F.A.C.)
A. Observe if the following requirements for medications and fluids are being met:
3. Meetings held quarterly to review safety policies, procedures, unusual occurrences, safety
issues, and audit compliance with safety policies and procedures.
1. Storage area is secured by a locking mechanism.
4. Safety audit results communicated to all program personnel.
2. All items are inventoried at least monthly.
5. Minutes of meetings recorded and retained on file for 2 years.
3. Deteriorated or expired items are stored in a quarantine area, separate from
usable items.
Comments:
I, the undersigned representative of the above service, acknowledge receipt of a copy of this inspection narrative, applicable supplemental inspection reports and corrective action
statement (if applicable). In addition, I am aware of the deficiencies listed (if any) and understand that failure to correct the deficiencies within the established time frames will
subject the service and its authorized representatives to administrative action and penalties as outlined in Section 401, F.S., and Chapter 64J-1, F.A.C. Copy of Inspection report
and Corrective Action Statement Received by:
Person in Charge: _____________________________________________________________ Date: _______________________________
Inspected By: _________________________________________________________________ Date: _______________________________
STATE OF FLORIDA
DEPARTMENT OF HEALTH  EMERGENCY MEDICAL SERVICES
SERVICE RECORDS AND FACILITIES INSPECTION REPORT (SECTION 401.31, F.S.)
Service Name: ____________________________________________________________ Inspection Date: ______/_______/_____ Phone: (___)_____________________
County: ________________________ Type of Inspection:  Initial  Reinspection  Random  Complaint Announced  Unannounced
License Type: ______  Transport  Nontransport Date of Last Inspection: _______/_______/_______ License Expiration Date: _______/_______/________
Inspection Codes:
Rating Categories:
1 = Item meets inspection criteria.
1 = Lifesaving equipment, medical supplies, drugs, records or procedures
1a = Item corrected during inspection to meet criteria.
2 = Intermediate support equipment, medical supplies, drugs, records or procedures
2 = Items not in compliance with inspection criteria.
3 = Minimal support equipment, medical supplies, records or procedures
I. ADMINISTRATIVE AND RECORDS STORAGE (Chapter 64J-1, F.A.C.)
1. Records storage and security.
4. Items are stored in a climate controlled (i.e. – heated and air conditioned) location.
2. Records storage for 5 years.
II. RECORDS (Section 401, F.S., Chapter 64J-1, F.A.C)
5. The area is clean and sanitary.
1. Current service license on display. (Chapter 64J-1, F.A.C)
B. Observe if the following requirements for controlled substances are being met:
2. Vehicle/Aircraft Records (Chapter 64J-1, F.A.C.) To Include:
1. The requirements listed in items 105 above are being met.
A. Registration.
2. Medical director has registered storage areas with DEA (Chapter 64J-1, F.A.C.)
B. Verification of vehicle permit.
C. Written operating procedures for the storage and handling of fluids and medications specify the
following:
3. Previous Inspection Forms, (Chapter 64J-1, F.A.C.)
1. Security procedures.
2. Items stored in a climate controlled location (i.e. – Heated and air conditioned)
4. Personnel Records for each EMT, paramedic (Chapter 64J-1, F.A.C.)
To Include:
A. Date of employment.
3. Deteriorated or expired items stored in a quarantine area, separate from usable items.
B. Record of training.
4. Inventory procedures.
C. Current professional certification.
D. Written operating procedures for the storage and handling of controlled substances specify the
following:
D. Documentation of completion of the 1988 D.O.T. Air Medical Crew
1. Storage procedures.
National Standard Curriculum-Advanced, for Paramedic Crew members
(Chapter 64J-1, F.A.C.)
5. Ambulance driver record (for each per Section 401.281(1), F.S.)
2. The positions that have access to controlled substances.
To include: Statements attesting to A.B.C.
A. 18 years old.
3. Shift change inventory procedures for vehicles.
B. Not addicted to alcohol or controlled substances.
4. Procedures to be used for the documentation of use, disposal of excess and resupply of
vehicles with controlled substances.
C. Free from physical or mental defect or disease that would impair
5. Procedures used for inventory discrepancies.
ability to drive.
D. Driving record verification.
F. Verify that the following occurs with regard in controlled substances:
E. Possess valid class “D” or chauffeur license.
1. Storage records are maintained on file at the location where he controlled substances are
stored.
F. Is trained in safe operation of emergency vehicle – 16 hour E.V.O.C.
2. All required inventories and records are maintained at least two years.
G. Possesses a valid American Red Cross First Aid and Personal
3. Records are maintained separately from other records.
Safety card or its equivalent.
H. Possesses a valid American Red Cross or American Heart
8. Equipment substitutions when authorization by medical director (Chapter 64J-1, F.A.C.)
Association CPR or ACLS card.
NOTE: Current EMT or paramedic certification is evidence of compliance with
9. Biomedical Waste operating procedures (Section 381.80, F.S. and Chapters 64J-1, F.A.C.) to
items A, B, C and G above. (Section 401.27(4), F.S.)
include:
6. Medical Director (Section 64J-1, F.A.C.)
A. Proper handling
A. Qualifications: Current ACLS certification or board certification in
B. Proper storage
emergency medicine (Chapter 64J-1, F.A.C.)
B. Duties and responsibilities (Chapter 64J-1, F.A.C.)
C. Proper disposal
1. Write/review operating procedures for patient care.
10. EMS providers disaster plan integrates both local and regional disaster plan (Chapter 64J-1,
F.A.C.)
2. Written quality assurance program operating procedures that require the
11. Adult and pediatric CID approval in writing by medical director (Chapter 64J-1, F.A.C.)
following:
a. Prompt review of run reports.
12. If an EMS provider maintains an air ambulance license or has permitted aircraft, the
following record requirements that apply (Section 401.251 F.S. and Chapter 64J-1, F.A.C.)
b. Direct observation of personnel.
A. Emergency protocol for overdue aircraft, when radio communications cannot be established,
or when aircraft cannot be located.
B. Documentation of flight done every 15 minutes while enroute to and from patient’s location.
3. Documentation of implementation of #2 above.
4. Documented of participation in direct contract time with EMS Field Level
C. Safety committee to include:
Providers for a minimum of 10 hours per year.
1. Membership of one pilot, one flight medical crew member, medical director, EQ
representative and one hospital administrator (if hospital based).
7. Inventory, storage and security procedures for medications, fluids and controlled
2. Written safety procedures.
substances (Sections 499, 893, F.S., and Chapters 64J-1, F.A.C.)
A. Observe if the following requirements for medications and fluids are being met:
3. Meetings held quarterly to review safety policies, procedures, unusual occurrences, safety
issues, and audit compliance with safety policies and procedures.
1. Storage area is secured by a locking mechanism.
4. Safety audit results communicated to all program personnel.
2. All items are inventoried at least monthly.
5. Minutes of meetings recorded and retained on file for 2 years.
3. Deteriorated or expired items are stored in a quarantine area, separate from
usable items.
Comments:
I, the undersigned representative of the above service, acknowledge receipt of a copy of this inspection narrative, applicable supplemental inspection reports and corrective action
statement (if applicable). In addition, I am aware of the deficiencies listed (if any) and understand that failure to correct the deficiencies within the established time frames will
subject the service and its authorized representatives to administrative action and penalties as outlined in Section 401, F.S., and Chapter 64J-1, F.A.C. Copy of Inspection report
and Corrective Action Statement Received by:
Person in Charge: _____________________________________________________________ Date: _______________________________
Inspected By: _________________________________________________________________ Date: _______________________________