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HomeMy WebLinkAbout011216wsa Agenda PackageHarnett County Board of Commissioners Special Session Tuesday, January 12, 2016 9:00 am 9:00 am Shawtown Alumni Association Presentation, President John F. Smith Sr. 9:30 am Sheriffs Office requests three additional deputy positions, Sheriff Larry Rollins 9:45 am EMS System Plan Renewal review, Ricky Denning, EMS Division Chief 10:00 am Emergency Services requests approval to create a new position and reclassify a current position, Emergency Services Director Jimmy Riddle 10:15 am Engineering and Facilities requests approval to reclassify two heavy equipment operator positions, Amanda Bader, County Engineer 10:30 am I.T. requests approval to reorganize which includes reclassification of two positions, Ira Hall, Information Technology Director 10:45 am Health Department requests approval to reclassify a Public Health Nurse position, John Rouse, Health Director 11:00 am Health Department requests approval to enter into a MOU with Harnett Health to provide morgue services, John Rouse, Health Director 11:15 am County Manager's Report: - Legislative Priorities/Luncheon Agenda (February 1st) - Planning Retreat Agenda (March 1St) - Donation request from Harnett Central High School Choral Booster Club - Boards and Committees on which commissioners serve - HFTC Update - January 19, 2016 Regular Meeting Agenda Review 12:00 pm Closed Session 12:30 pm Adjourn Board Meeting Agenda Item SahKary !9 ,2D1G MEETING DATE: Deeentber 21, 2015 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: New position request REQUESTED BY: Sheriff Rollins REQUEST: Sheriff Rollins is requesting three additional Deputy positions. See attachement /Budget Amendment. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: F: \2015 -2016 \agenda New poistions.doc Page 1 of 1 BUDGET ORDINANCE AMENDMENT BE IT ORDAINED by the Governing Board of the County of Harnett, North Carolina, that the following amendment be made to the annual budget ordinance for the fiscal year ending June 30, 2016: Section 1. To amend the General Fund, Sheriff's Department, the appropriations are to be changed as follows: EXPENDITURE AMOUNT AMOUNT CODE NUMBER DESCRIPTION OF CODE INCREASE DECREASE 110 - 5100 - 420 -11 -00 Salaries & Wages 55,062 110 - 5100 - 420 -21 -00 Group Insurance Expense 10,566 110 - 5100 - 420 -21 -05 Insurance Expense — Employee Clinic 450 110 -5100- 420 -22 -00 FICA Tax Expense 4,176 110 - 5100 - 420 -23 -02 LEO Retirement 3,942 110 -5100- 420 -23 -05 LEO Supplemental Retirement 2,754 110 -5100- 420 -25 -10 Unemployment Benefits 558 110 -5100- 420 -26 -08 Worker's Compensation 2,160 110 - 5100 - 420 -74 -74 Capital Outlay 73,164 110- 5100 - 420 -60 -36 Uniforms 7,650 110 - 5100 - 420 -60 -29 Weapons 5,670 110 - 5100 - 420 -60 -65 Auto supplies 12,393 110 -5100- 420 -60 -33 Materials and Supplies 1,200 REVENUE AMOUNT AMOUNT CODE NUMBER DESCRIPTION OF CODE INCREASE DECREASE 110 -0000- 399 -00 -00 Fund Balance Appropriated 179,745 EXPLANATION: To fund the addition of three new Deputies (hire date 01/01/16) with associated vehicles, uniforms and equipment for each. APPROVALS: Finance Officer (date) County Manager (date) '- Department Head (date) Section 2. Copies of this budget amendment shall be furnished to the Clerk to the Board, and to the Budget Officer and the Finance Officer for their direction. Adopted this day of , 2015. Margaret Regina Wheeler, Jim Burgin, Chairman Interim Clerk to the Board Harnett County Board of Commissioners Monthly cost Six month cost Six Month cost Deputy III Per Deputy per Deputy for three Deputies Salary $3,059 $18,354 $55,062 FICA $232 $1,392 $4,176 LEO Retirement $219 $1,314 $3,942 Insurance Expense $587 $3,522 $10,566 Employee Clinic $25 $150 $450 Workers Comp. $120 $720 $2,160 LEO Supplement Ret. (401K) $153 $918 $2,754 Unemployment Ins. $31 $186 $558 Total $4,426 $26,556 $79,668 Uniforms per Deputy x3 Bulletproof vest x3 $2,000 $6,000 $550 $1,650 Total $2,550 $7,650 $7,650 2016 Dodge Charger x3 Taxes x3 $23,677 $71,031 $711 $2,133 $24,388 $73,164 Emergency equipment per veh. $3,000 $9,000 Install $800 $2,400 Graphics $325 $975 Tags x3 $6 $18 $4,131 $12,393 $73,164 $12,393 Handgun $575 $1,725 Shotgun $500 $1,500 Tazer $815 $2,445 Total $1,890 $5,670 $5,670 Phones (need 2) $600 $1,200 $1,200 $179,745 Board Meeting Agenda Item MEETENG DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Approval of the EMS System Plan Renewal REQUESTED BY: Jimmy Riddle, Emergency Services Director REQUEST: Request for approval of the EMS System Plan Renewal. The EMS System Plan Renewal currently has to be approved by the Harnett County Board of Commissioners. The EMS System Plan describes how Harnett County provides the citizens with 24/7 EMS coverage. The plan includes the individual EMS departments that provide these services including the 911 center. The plan explains the training for our EMS personnel and the staffing of our EMS units. Request for approval to designate the County Manager signature authority for any EMS System Plan renewals or changes forward. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: C:1Users\bstancil\AppData \ Local \ Temp \agendafonn20 I 6-EMS Plan Renewal Approval_4508583 \agendaform2016 -EMS Plan Renewal Approval.doc Page 1 of 1 County of Harnett Emergency Medical Services System Plan Mission To ensure Harnett County citizens, patrons and visitors are provided the highest level of prehospital care in the most efficient, professional and cost - effective manner. SECTION I: SYSTEM OVERVIEW a. Harnett County is located in the south central portion of North Carolina. The county is 642 square miles and according to the 2010 census has 114,678 citizens. The following counties border Harnett County: Sampson, Johnston, Wake, Chatham, Lee, Moore and Cumberland. b. The following is a list of all providers located in Harnett County, the level of care provided, how it is provided and the square miles of the service area: Anderson Creek EMS - EMT -I level with combination of paid and volunteers (120 square miles) Benhaven EMS — EMT -I Level with combination of paid and volunteers (140 square miles) Boone Trail EMS — EMT Level with combination of paid and volunteers (65 square miles) Buies Creek EMS — EMT Level with combination of paid and volunteers (42 square miles) Coats Rescue — EMT Level with combination of paid and volunteers (60 square miles) Dunn Rescue — EMT -P Level with combination of paid and volunteers (120 square miles) Erwin Rescue — EMT Level with combination of paid and volunteers (40 square miles) Harnett County EMS — EMT -P Level with paid employees (642 square miles) Lillington Fire — MR Level with combination of paid and volunteers (10 square miles) Spout Springs Fire — MR Level with combination of paid and volunteers (46 square miles) Each area has 24/7 coverage by Harnett County EMS and/or squad paid and volunteer personnel. c. The following providers are dispatched through the Harnett Central Communications center. Anderson Creek EMS — Harnett Central Communications Center with a Paramedic Benhaven EMS — Harnett Central Communications Center with a Paramedic Boone Trail EMS — Harnett Central Communications Center with a Paramedic Buies Creek EMS — Harnett Central Communications Center with a Paramedic Coats Rescue — Harnett Central Communications Center with a Paramedic QRV Dunn Rescue — Harnett Central Communications Center with a Paramedic ambulance Erwin Rescue — Harnett Central Communications Center with a Paramedic ambulance Harnett County EMS — Harnett Central Communications Center with a Paramedic ambulance Lillington Fire — Harnett Central Communications Center with a Paramedic ambulance Spout Springs Fire - Harnett Central Communications Center with a Paramedic ambulance d. The following specialty care transport programs may be used in Harnett County for the following situations. Harnett County EMS — One wheelchair bus 12 hours a day Monday through Friday. One 24 hour transport unit stationed at Dunn Emergency Services Building. One 24 hour transport unit stationed at Angier Fire Department. Carolina Air Care — 911 scene response and patient transports from hospitals in the county. Air unit stationed at 1638 Owens Drive Fayetteville Lat. N 35 01 96 Long. W 78 55 92 2 Duke Life Flight — 911 scene response and patient transport from hospitals in the county Unit located at 2301 Erwin Road Durham Lat. N 36 00 79 Long. W 78 23 24 Unit Located at 3149 Swift Creek Road Smithfield Lat. N 35 32 27 Long. W 78 23 25 Duke Life Care ground ambulance — patient transport from hospitals in the county UNC ground ambulance — patient transport from hospitals in the county Wake Mobile — patient transport from hospitals in the county Wake Air Mobile — 911 scene response and patient transports from hospitals in the county Unit located at 3000 New Bern Avenue Raleigh Lat. N 35 47 10 Long W 78 25 19 LifeLink — patient transport from hospitals in the county Vidant Air 2 Services - 911 scene response and patient transport from hospitals in the county Unit located at 7265 Air Terminal Drive Rocky Mount N.C. Lat. N 35 06 55 Long. W 77 03 51 The air medical transport unit will be contacted by the dispatch center per the Harnett County EMS System Policy and Procedures, and the request of the incident commander to proceed to the scene of the accident. The hospitals can also contact air medical transport and ground transport providers for transfers from the hospitals to other facilities. e. Each hospital provides orientation to their employees regarding the receiving of EMS patients. EMS personnel will assist on an as needed basis. The appointed nurse liaison at each hospital will ensure that the orientation and education is provided to the hospital staff. f. Harnett County is fortunate to have available, if the situation arises, several specialty teams that will be dispatched by Harnett Central Communications at the request of the incident commander. The teams available are: 1. Harnett County Dive Team 2. Harnett County Search and Rescue 3. STAR (Special Tactics and Rescue) Team — for confined space and high level rescue 4. Trench Team — for trench and structural collapse 5. SMAT III Team- for state -wide multi - hazard responses 6. 2 — Decontamination Teams with equipment 7. g. The following Paramedic QRV ALS zones are established in Harnett County and were created to ensure parity level of patient care to anyone needing assistance in Harnett County: Anderson Creek- Harnett County EMS Paramedic stationed at Flat Branch Fire Department on Anderson Creek Ambulance Harnett County EMS Paramedic stationed at Anderson Creek Fire Department on Anderson Creek ambulance. Angier Fire — Harnett County EMS Paramedic ambulance stationed at the Angier Fire Department 3 Benhaven EMS — Harnett County EMS Paramedic stationed at Spout Springs Fire Department on Benhaven Ambulance Harnett County EMS Paramedic stationed at Benhaven Station 1 on Benhaven ambulance Boone Trail EMS — Harnett County EMS Paramedic stationed at Boone Trail station 1 on Boone Trail ambulance. Buies Creek Fire — Harnett County EMS Paramedic stationed at Buies Creek Fire Department on Buies Creek Ambulance Coats Rescue — Harnett County EMS QRV Paramedic stationed at the department Dunn Rescue — Paramedic on first & second out Ambulance during day hours and QRV Paramedic at night Erwin Rescue — Dunn Paramedic on Erwin ambulance stationed at Erwin Fire Department Harnett County EMS — Paramedic Ambulance at the North Harnett Fire station. Lillington Fire — Harnett County EMS Paramedic Ambulance at the Flatwoods station Harnett County EMS — Paramedic Ambulance /QRV at EMS Base in Buies Creek h. See Section VI — Data Collection regarding Data Collection for Harnett County. i. Overall management of the Harnett County EMS System include: 1. Patients will be triaged and transported to the appropriate facility, if the closet facility is not indicated. An example will be a psychiatric patient experiencing a psychiatric crisis will be transported to appropriate facility because that facility provides psychiatric services. 2. The Harnett County EMS System transports to fifteen different hospitals. We have two hospitals in Harnett County. In order to reach the other facilities, the county line is crossed. Any of these facilities are appropriate transports for the system due to proximity and also patient preference. Hospitals that we routinely transport to are: Harnett Health Betsy Johnson Dunn, Harnett Health Central Harnett Lillington, Wake Medical Center Raleigh,Cary&Apex, Rex Health Care Raleigh, Duke Health Raleigh & Durham, Central Carolina Hospital Sanford, UNC Hospital Chapel Hill, Cape Fear Valley Fayetteville, Womack Army Hospital Ft. Bragg, Johnston Medical Center Clayton & Smithfield, First Health Moore Regional Pinehurst. 3. The local hospital has a diversion policy. If diversions are needed it is entirely a case by case basis in which the hospital will arrange the receiving of the patient that was intended for hospital A and needed to be transported to hospital B. 4. Harnett County has an established goal of 10 minute or less response time for calls within the county. This is monitored on a monthly basis by the system. 4 J. 5. See attached Harnett County Disaster Plan & Harnett County Mass Gathering Plan 6. Harnett County provides paramedic stand -by coverage for any and all public requests if the service is needed or desired. Examples include sky diving events, Fourth of July celebrations, high school football games, etc. Harnett County is involved in several injury prevention and community health programs. Agencies involved in these programs include: Harnett County Sheriff's Department, Dunn Police Department, Angier Police Department, Lillington Police Department, Harnett County Emergency Services, Dunn Rescue Squad, Coats Fire and Rescue, Erwin Fire and Rescue and various other organizations within the county. k. The Harnett County EMS System is an active member of the Caprac Trauma Regional Advisory Committee. See attached letter confirming membership. 1. The Harnett County EMS System has participated in several studies that have been sponsored by the Capital Trauma RAC in which the data was reviewed and incorporated as needed in the patient care protocols. 5 Section II: Communication A. Accessing the 911 system 1. Harnett Central Communications Center is presently using Enhanced 911 system. At the present time the center has (6) 911 lines and one seven -digit lines. All of the 911 lines and seven digit lines are taped and all have rollovers. The center can receive up to (6) 911 calls and (6) calls on the seven digit lines simultaneously. Calls are routed to Harnett Central from the various parts of the county that the center covers by selective call routing. This is important because some areas of the county are on the Sanford, Fayetteville, Raleigh, Johnston County, Sampson County, Lee, or Moore County telephone exchanges and these 911 calls would not be received at Harnett Central Communications without this technology. If calls are received by other communications they are transferred directly to Harnett Central Communications via a seven digit emergency number. All callers will talk directly with a telecommunicator in the communications center and will never be required to speak with more than two persons to request emergency assistance. In some cases, Harnett Central Communications receives calls that should have been routed to one of the out of county communications centers . Harnett Central Communications transfers these calls to the appropriate communications center. Emergency calls are typically transferred directly between the communications centers with the telecommunicator who took the call at the receiving center staying on the line until the call is taken at the correct center. Harnett Central Communications has a language line through Fluent Language Solutions that handles any language that they may encounter. B. Functions of the Communications Centers 7 1. Harnett Central Communications Center is a division of the Harnett County Sheriff's Department. Staffing presently consists of one Communications Supervisor. There are twenty six telecommunicators that are NC EMD's. All telecommunicators are trained to dispatch Fire/EMS calls or law enforcement calls. There are four to five EMD telecommunicators on duty at all times, one for Fire/EMS, one for the Harnett County Sheriff's Department, and one for the five municipal police departments also dispatched by Harnett Central. All telecommunicators are required to obtain the EMD credentials and are cross - trained in all areas. In addition, the communications supervisor is available Monday — Friday from 0700 — 1800 to assist with dispatching duties if needed. C. Dispatch of Emergency Resources 1. The Communications Center uses the Medical Priority Dispatch System, version 12.2 to dispatch initial EMS calls and mutual aid EMS calls. The Communications Center use the call determinates to determine what resources respond to each call. 2. See attached policy for dispatching other mutual aide and specialty equipment/resources to calls. D. Communications Hardware/Frequencies 1. All transport and QRV units have the capabilities of contacting each facility that a patient may be transported to via the State Viper system. As a backup, each unit has a cellular phone to contact the facility if needed. 2. Harnett Central Communications is currently using the State Viper system as their primary means of radio communications. Harnett Central Communications Center can communicate directly with Fire/EMS/Police via the Viper system. Harnett Central maintains VHF capabilities on 155.760 and 154.205 for the purpose of dispatching. Harnett Central Communications 8 has a backup generator at their center and at each communications tower in the event of a power outage. In the event of a natural disaster, Harnett Central Communications Center will be moved to Harnett County Emergency Services center or the backup center located in Clayton, which is in Johnston County. The phone company will switch the phone lines to Harnett County Emergency Services Center for the 911 system and the communications center functions as they normally do in their communication center. 3. Attached you will find copies of letters from Harnett Central in regards to their FCC radio licenses. They chose to write a letter due to the number of licenses they have to have to function. E. Communications Committee's 1. The Harnett County Chiefs Association formed a committee that involves ns, Harnett Central Communications Centers and representatives of all Emergency Services in Harnett County. This committee reviews all operations of communications. 2. There is a Communications Sub - Committee formed to address all technical problems that arise with the communications hardware. F. Quality Management Harnett Central Communications center performs monthly quality management reviews to address any trending problems and training concerns that will improve the communication process. 9 SECTION III: MEDICAL OVERSIGHT A. The Harnett County Board of Commissioners will appoint the Medical Director of the Harnett County EMS System. The Medical Director of the system shall meet the required criteria defined in the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection." Dr. Mark Glaser is the current Medical Director for the Harnett County EMS System. Dr. Glaser is a certified diplomat with the American Board of Emergency Medicine. Dr. Glaser. See attachments (American Board of Emergency Medicine letter dated December 27, 1996, Current Medical License with expiration date of 8/9/2016, Several certification cards, Copies of Certificates of Continuing Medical Education, Copy of Certificate of Attendance for NC EMS Medical Directors Course and Update on Domestic Preparedness, Copy of letter from Harnett County confirming appropriate medical liability coverage for Dr. Glaser, copyof letter from Dr. Glaser addressing NCCEP requirements_ Dr. Glaser can be reached at: Harnett County Emergency Services Center 910- 893 -7563 910 - 814 -2570 (fax) B. The Medical Director will be responsible for the following: (1) Ensure that medical control is available 24 hours a day (See Section III — G) (2) The establishment, approval and updating of treatment protocols as required. (See Section VII -F) (3) For the EMD program, establishment, approval and annual updating of the program. (See Section VII -F) (4) Medical supervision of the selection, system orientation, continuing education, and performance of EMS personnel. (See Section VII — and V — Al) (5) Medical supervision of the scope of practice performance evaluation for all EMS personnel in the system based on the treatment protocols for the system. (See Section V — A 1 and VII — B) (6) The medical review of care provided to patients. (See Section III — Eii) (7) Provide guidance regarding decisions about equipment, medical supplies, and medications carried on ambulances and QRV's. (See Section IV — F) (8) Ensure the care provided is up to date with current medical practice. (See Section 111— A, VII — F) 13 C. All ALS providers will function within the protocols established by the Harnett County EMS System. All EMD dispatchers will follow the protocols established by the Harnett County EMS System for EMD's. The EMS System policies, procedures and protocols are adopted following the NCCEP document guidelines. The Medical Director can suspend temporarily, pending due process review, any EMS personnel from further participation in the EMS system when it its determined the activities or medical care rendered by such personnel may be detrimental to the care of the patient, constitute unprofessional behavior, or result in non - compliance with privileging requirements. Due process consists of review and action by the Peer Review Quality Management committee or sub - committee (Peer Review Performance Sub - Committee). D. Harnett County Peer Review Quality Management Committee consists of the following voting representatives: 1) Medical Director (Chairman) 2) ED Physician from Harnett Health Hospital or Physician Representative 3) Nurse Liaison from Harnett Health Hospital 4) Harnett Health Hospital Representative 5) Harnett County Manager 6) A designated County Commissioner 7) EMS Provider — a representative from each provider Exofficio members include: County Attorney, Representative from Central Carolina Community College, Chief of Staff from Harnett Health Hospital and a representative from Harnett County Emergency Management. The committee will meet a minimum of four times a year and more often if needed. Each department will perform 100% quality assurance review. Each training officer will report the statistics and results of the designated review determined by the Medical Director with recommendations by the training officer. The information will be reported to the Peer Review Quality Management Committee. Each provider 14 in the system has data points assigned by the Medical Director that are reviewed on a quarterly basis. The results of the data points are reported to the Systems Continuing Education Coordinator and Medical Director. The results are also presented to the Peer Review Quality Management Committee. The acceptable percentage goal for compliance is 90% or above. The data points can be changed at the discretion of the Medical Director when the percentage goal is met. If the compliance is less than 90 %, the provider will review these data points again for the next quarter and be recommended to cover these data points in there continuing education by the Medical Director. Harnett County will have a Critical Intervention Peer Review Sub - Committee responsible review of all critical interventions in the Harnett County EMS System. This sub - committee is tasked with reporting their findings to the Medical Director with any recommended actions or remediation. The Medical Director will then report these findings to the Peer Review Quality Management Committee at each quarterly meeting. This committee will consist of one EMT - Paramedic from each Paramedic provider under the medical oversight of the Harnett County EMS System approved by the Medical Director. The following guidelines are established for the Due Process procedure for the Peer Review Performance Sub - Committee. Members of the Peer Review Performance Sub - Committee include: • ALS Medical Director (Chairman) • County Attorney • Peer Review Quality Management Committee Medical Physician (One of the ED physicians) • An EMT - Paramedic from each Paramedic provider (minimum of one EMT -P) This committee will meet on an as needed basis. The decisions made by this subcommittee will be considered final. The following will apply to the Peer Review Performance Subcommittee a. A simple majority of the committee must be available to hold a committee meeting. b. The Medical Director or his/her designee must be present at the meeting. 15 c. Individuals required to appear before the committee will be notified as soon as possible and will be accompanied to the meeting with the chief or director of their agency /provider. d. If the individual requested to appear before the committee is not present the committee will meet and take appropriate action. e. The individual will be given the opportunity to discuss the details of the questioned action and the committee can ask appropriate questions of the individual. f. The committee will review and discuss the findings and make a decision. If possible the individual will be informed of the decision at the time of the meeting. In the event that a decision cannot be made at the time of the meeting, the chairman will notify the individual as soon as possible, either by phone or in person. g. A written summary will be provided to the individual and their chief officer. h. Minutes of the Peer Review Performance Subcommittee meeting will be maintained and regarded "confidential." ii. The Peer Review Quality Management Committee meeting minutes will be maintained by the EMS system and maintained at the department designated by the Medical Director. That location is Harnett County Emergency Services Center. All documents and meeting minutes of all committees are considered confidential and can only be reviewed by committee members. Each committee member for the Peer Review Quality Management Committee is appointed by each agency listed. The Peer Review Quality Management Committee officers will be appointed by the Harnett County Board of Commissioners and/or the Medical Director (chairman of the committee). The length of term on the Peer Review Quality Management Committee is ongoing/continuous. There are no established requirements regarding attendance. A simple majority of the Peer Review Quality Management Committee must be available to conduct business. 16 E. On —line medical direction will be provided to EMS personnel as follows: • On -line medical direction is restricted to medical orders that fall within the scope of practice of EMS personnel in the approved treatment protocols for the Harnett County EMS System. • Physicians, EMS - physician assistants or EMS — Nurse Practitioners provide on -line medical direction. Only physicians may deviate from the written treatment protocols for the Harnett County EMS system. • On -line medical direction will be provided by two -way voice communication that is maintained throughout the entire patient encounter. F. Harnett Health Hospitals will provide online medical direction for the Harnett County EMS system. Each facility has a physician, EMS - physician assistant or EMS -Nurse practitioner available 24 hours a day. A physician is available for back up to the EMS -PA and EMS -NP to provide on -line medical direction. Each hospital will have a representative as a voting member on the Peer Review Quality Management Committee that will be able to provide feedback to the committee. The representative for each hospital will ensure that each person responsible for providing on -line medical direction will be provided current and up to date treatment protocols for the Harnett County EMS System. 17 SECTION IV: VEHICLES, EQUIPMENT, SUPPLIES A. The Harnett County EMS System has 29 permitted ambulances and 7 permitted QRV's stationed strategically throughout the county to provide 24 -hour EMS coverage. Each provider in the Harnett County EMS System is responsible for providing maintenance on the permitted units for their department. It is the responsibility of each EMS provider to maintain their maintenance records, and keep these on file for the length of time the vehicle is in service. B. Documentation of permitted ambulances is on file at the Harnett County EMS office. C. See attached Harnett County EMS System Occupational Exposure to Bloodborne Pathogens and Tuberculosis Exposure Control Plan (January 2013 version). All providers in the Harnett County EMS System are required to take the established Department of Insurance Emergency Vehicle Driving Course. Records are maintained by each departments training officer and on file at the Harnett County EMS office. All EMS personnel privileged at the MR or above level in the Harnett County EMS System are allowed to drive permitted vehicles. The curriculum/training is provided by Central Carolina Community College. The Harnett County EMS System has a standardized minimum supply and equipment list for all permitted ambulances and QRV's. The lists are reviewed and approved by the medical director on an annual and as needed basis. The list is attached for each level of care provided. D. It is the responsibility of each EMS provider to keep all units clean and properly maintained at all times. Daily inspections are done on all first line units. This ensures that no medications or equipment are expired on each unit. This is documented on a daily inspection sheet that is maintained at each provider's base of operations, for a minimum of 30 days. 18 Harnett County EMS System will store all medications in a temperature- controlled atmosphere according to manufacturer specifications. Examples of how to accomplish this when necessary are: Leave trucks running at the hospitals but not in front of access doors or under canopies at access doors, take drugs off vehicles with keys attached to the drug bags or boxes and temperature control when cold with heated bays which every provider in the Harnett County EMS System has available, etc. 19 SECTION V: PERSONNEL A. Privileging for EMS Personnel 1. Individuals that will enter into the Harnett County EMS System must meet the following criteria before functioning in the Harnett County System. a. Provide proof of current continuing education hours. b. Provide a current State certification at the level they will function in the system. c. EMT - Paramedics will show proof of ACLS, ITLS/PHTLS, and PALS/PEPP and CPR or provide proof of completing topics and skills. d. EMT -I and EMT -P are required to complete a written/skills /performance review at the level the individual will be privileged in the Harnett County EMS System. EMD, EMR, & EMT — level personnel may be privileged by the Training Officer at their department. This is at the discretion of the Medical Director. Procedures for privileging these individuals are contained in the document entitled: "Educational Guidelines and Training Officers Resource ". e. After successful completion of the skills evaluation, and performance review the EMD, EMR, EMT, will be allowed to function in the Harnett County EMS System. f. After successful completion of written examination, skills evaluation, oral boards, and performance review the EMT -I will be required to precept in the field under the supervision of an approved preceptor /field training officer. The amount of calls that will be successfully completed will be determined by the Medical Director. If the evaluations reflect that an individual needs additional remediation it will be assigned by the Medical Director. 20 The amount and/or details of such remediation will be at the discretion of the Medical Director. g. After successful completion of the written examination, skills evaluation, oral boards, and performance review the EMT -P will be required to precept in the field under the supervision of an approved system preceptor /field training officer; The amount of calls that will be successfully completed is at the discretion of the Medical Director. If the evaluations reflect that an individual needs additional remediation it will be assigned by the Medical Director. The amount and/or details of such remediation will be at the discretion of the Medical Director. h. All EMT- I/EMT -P will be required to complete performance evaluations on each call for the quantity assigned by the Medical Director, once complete, the evaluations must be turned into the Systems Continuing Education Coordinator for review and approval by the Medical Director. The EMT - I/EMT -P and EMS provider will receive a written letter from the Medical Director confirming satisfactory /unsatisfactory completion of all requirements for the Harnett County EMS System. j. See attached: Personnel Verification Form; Privileging/Re- Privileging; Current Harnett County EMS System Roster k. These individuals will have 6 months to complete this process or they may or may not repeat this entire process at the discretion of the Medical Director. 2. Approved Preceptor /Field Training Officer 1. EMT -I Preceptor must have the following: a. A minimum of one year of field experience as an EMT -I. b. A minimum of six months field experience as an EMT -I in the Harnett County EMS System. c. Attendance at an approved preceptor's workshop. d. Approval by the Medical Director. 21 e. Approval by the provider Chief or Director. 2. EMT -P Preceptor /Field Training Officer must have the following: a. A minimum of one -year field experience as an EMT -P. b. A minimum of six months field experience as an EMT -P in the Harnett County EMS System. c. Attendance at an approved preceptor's/Field Training Officer Workshop. d. Approval by the Medical Director. e. Approval by the provider Chief or Director. 3. Maintaining Preceptor/Field Training Officer Status a. All preceptors /field training officers must attend a preceptor's/FTO workshop annually. b. All preceptors /FTO must remain certified at their present level. c. All preceptors/FTO must maintain good standing with the Medical Director and EMS System. d. All preceptors /FTO must maintain approval by the provider Chief or Director to function as a preceptor. B. Training Officer Requirements 1. In order to be eligible to serve as a Training Officer in the Harnett County EMS System, the candidate must: a. Be privileged at the highest certification level provided by his or her EMS Agency. b. Have 2 years of field experience (at the highest level of certification provided by the EMS agency). c. Have 1 year experience in the Harnett County EMS System d. Remain in good standing within the system. 22 e. Be familiar with the Educational Guidelines and Training Officers Resource Manual. f. Attend an orientation on the Educational Guidelines and Training Officers Resource Manual. g. Be familiar with the Education Section of the Harnett County EMS Systems Plan. h. Be available for meetings such as Peer Review, Training Officers meetings or unscheduled but necessary meetings or training sessions (as needed). C. Staffing Requirements Each provider will ensure that their service area is covered 24 hours a day by properly privileged personnel in the Harnett County EMS System. See attached Harnett County EMS provider contract. D. Non - Traditional Practice Settings At the present time the Harnett County EMS System will not use EMS personnel in a non - traditional practice setting. 23 SECTION VI: DATA COLLECTION 1. All providers in the Harnett County EMS System are reporting the data points that are required by the NCCEP document by January 1, 2005. The Harnett County EMS System has software that meets the Model system requirement for transmitting the data required by OEMS. Each EMS provider in Harnett County utilizes EMS Charts which exports this data to PreMis every 24 hours. 2_ This data will be available for the Harnett County EMS Medical Director daily at the Harnett County EMS office. 3. The original PCR reports, (digital or paper), are to be maintained a minimum of 12 years at each individual provider. 25 SECTION VII: EDUCATION A. Continuing Education 1. The Medical Director will provide requirements for continuing education. Each provider will have a designated training officer who will maintain the training at each department. The training officer will select topics to be covered in continuing education for the department following guidance from the National Education Standards and Scope of Practice model as well as educational requirements set in rule by the NCOEMS. These topics will be submitted to the Medical Director for approval annually. The continuing education schedule will follow the January 1 — December 31 calendar. The continuing education will be handled through a state approved teaching facility (i.e. Central Carolina Community ColIege), and will be coordinated by a Level 1 instructor. In -house education will be accepted through the approved Teaching Facility as long as the instructor requirements are met and the Medical Director has approved the offering. The training officer will be able to make changes to the continuing education schedule if the need arises due to needs identified during Peer Review, but must be approved by the Medical Director before the changes are made. The procedure a training officer should follow when altering the continuing education schedule is outlined in a document entitled: "Educational Guidelines and Training Officer's Resource ". Protocol 26 updates and/or new skills, equipments and/or drug_changes are included in continuing education and will be added to the schedule on an as needed basis. 2. EMR, EMT, EMT -I and EMT -P level personnel must have 24 hours of continuing education per year, and attend classes covering content specified by the National Education Standards, Scope of Practice Model and educational requirements as set by the NCOEMS. EMD level personnel must have 18 hours of continuing education per year. 3. Continuing education hours may be awarded through a variety of traditional and non - traditional methods. (i.e. seminars, conferences, professional meetings, peer review and other methods approved by the Medical Director). All EMS personnel are encouraged to attend classes, conferences or seminars to promote professional development for the individual. Individuals that work or volunteer in other EMS systems can provide their continuing education hours to the department training officer and receive credit. All mandatory educational offerings identified as Harnett County specific must be attended in Harnett County classes unless otherwise approved by the Medical Director. 4. The Medical Director will maintain the continuing education requirements set forth by the NCCEP standards and will be required to attend the Medical Directors Update annually as offered by the NCOEMS. The Medical Director will also stay up to date on topics that are relevant to the prehospital setting. The Medical Director will provide copies of all 27 continuing education to the Systems Continuing Education Coordinator, which will be entered into the Harnett County EMS system database. The Medical Director will respond to EMS calls in the system as required by the NCCEP and NCOEMS rule. 5. The Training Officers from each department will submit the continuing education schedule by December 1st of each year to the Medical Director for review and approval. A copy of schedules for each department will be available so providers may attend classes throughout the County if needed. If a change is needed in the schedule the Training Officer will submit the change to the Medical Director for approval and forward the information to the other providers in the system. 6. The Education Committee and Medical Director will review the continuing education program on an annual basis. The Education Committee is comprised of all department training officers in the Harnett County EMS System and the Medical Director. The Chairman of the Committee is the Systems Continuing Education Coordinator. The committee meets at least annually or on an as needed basis. This committee develops educational goals and reviews all continuing education programs for the Harnett County EMS System. 7. The educational goals of the Harnett County EMS System will be consistent with the National Education Standards, Scope of Practice Model and Educational requirements set by the NCOEMS. Instructors delivering education in the system are expected to be qualified and 28 approved through the State approved Teaching Facility and the system Medical Director. The quality of educational offerings is important and we encourage students to provide feedback through the System Continuing Education Coordinator and/or approved Teaching Facility. B. Re- Privileging 1. The educational hours of all EMS Personnel will be reviewed annually. It is the policy of the Harnett County EMS System that if an individual is deficient in hours the individual will be contacted and given a designated period of time to become current with the hours. If the individual does not meet the annual 24 hour (18 hours for EMD) continuing education requirements the Medical Director may suspend the individual from the EMS System until the hours are made up. If this occurs more than once in a four year period the Education Committee will review the situation and make recommendations to the Medical Director for his/her decision about the individual continuing to participate in the Harnett County EMS System 2. All EMS personnel will be required to successfully complete a scope of practice performance evaluation during their credential period. The scope of practice performance evaluation can be assessed through a variety of methods including; simulated patient scenarios, classroom skill reviews and/or through the peer review and performance improvement program (i.e. review of actual call performance). Most of the scope of practice performance evaluations will be completed in the course of regularly scheduled training sessions, however 29 additional sessions will be held as needed. The Medical Director can require any provider to complete a scope of practice performance evaluation at his/her discretion. The individual must be up to date with the continuing education requirements at the time of recredentialing (24 hours per year and all topics mandated by the EMS System and/or educational standards). 3. The department Training Officer will assess clinical skills and complete and maintain skill/scenario checklists for each individual when applicable. Clinical skills can be assessed using a variety of methods including; simulated patient scenarios, classroom skill reviews and/or through the peer review and performance improvement program (i.e. review of actual call performance). 4. The scope of practice performance evaluation will be assessed using protocol - based modules (simulated scenarios or "on call" performance review). The scope of practice evaluation should incorporate the recommended baseline skills for each credentialing level as outlined in the North Carolina College of Emergency Physicians Standards for EMS Patient Care Procedures (Skills) and Protocols. Below are a list of simulated and/or performance review based scenarios that will be assessed: EMD Scope of Practice Evaluation - Emergency Medical Dispatchers will be expected to demonstrate their ability to successfully manage the following scenarios using the approved card sets: a. Chest pain b. Cardiac Arrest (medical, trauma or pediatric) c. Dyspnea d. Normal or Abnormal Childbirth e. At least one of these performance evaluations must be on a pediatric patient. 30 EMR Scope of Practice Evaluation - Emergency Medical Responders will be expected to demonstrate their ability to successfully manage the following patient events: a. Cardiac Arrest (medical, trauma or pediatric) b. Dyspnea c. Musculoskeletal (Fracture or Dislocation) d. Spinal Injury (with or without neurological deficit) e. At least one of these performance evaluations must be on a pediatric patient. f. System allergic reaction utilizing EPI IM protocols /procedures (Annually) EMT Scope of Practice Evaluation - EMTs will be expected to demonstrate their ability to successfully manage the following patient events: a. Cardiac Arrest (medical, trauma or pediatric) b. Dyspnea c. Musculoskeletal (Fracture or Dislocation) d. Spinal Injury (with or without neurological deficit) e. Systemic Allergic Reaction utilizing EPI IM protocols /procedures (Annually) f. At least one of these performance evaluations must be on a pediatric patient. EMT - Intermediate Scope of Practice Evaluation- EMT - Intermediates will be expected to demonstrate their ability to successfully manage the following patient events: a. Chest pain b. Cardiac Arrest (medical, trauma or pediatric) c. Altered Mental Status /Syncope /Seizure d. Dyspnea e. Systemic Allergic Reaction f. At least one of these performance evaluations must be on a pediatric patient. Paramedics Scope of Practice Evaluation - EMT - Paramedics will be expected to demonstrate their ability to successfully manage the following patient events: a. Chest Pain b. Cardiac Arrest (medical, trauma, pediatric) c. Altered Mental Status/Syncope /Seizure d. Dyspnea e. Systemic Allergic Reaction f. At least one of these performance evaluations must be on a pediatric patient. 31 There will be an evaluation form done for each scenario and a skills sheet completed when applicable. If the individual does not successfully complete the scope of practice performance evaluation the individual will be remediated at another time by the Training Officer and scheduled a time with the Medical Director and/or his/her designee to complete the scope of practice evaluation. 5. EMD, EMR, & EMT — level personnel may be privileged/re- privileged by the Training Officer at their department in conjunction with the State Teaching Facility after all requirements have been met. 6. Forms, procedures and regulatory information concerning Continuing Education and Re- privileging are contained in the document entitled: "Educational Guidelines and Training Officer's Resource ". Nothing in this manual will conflict with any part of the EMS Plan. 7. For EMT- I/EMT -P levels, after successful completion of the educational requirements the department Training Officer will complete the Harnett County Certification Verification form with the provider, which will be forwarded for approval by the Medical Director and processed for State re- credentialing. 8. Recredentialing materials must be completed and forwarded to the State approved Teaching Facility in a timely manner. All materials are expected to be submitted for review by the Medical Director no later than the 30 days prior to the provider's expiration date. 32 C. Training Officers 1. Each Department Training Officer will maintain and make available upon request (or as scheduled) to the EMS Systems Office the following: a. Continuing Education topics/hours b. Peer Review and Performance Improvement data by the 15th working day of the month prior to the Peer Review meeting c. Updated rosters (additions and deletions) 2. It is required that the Training Officer maintain a record of all education at each department. This information will be available for audit by NCOEMS, Harnett County System Continuing Education Coordinator, Harnett County System Coordinator and the Medical Director only. 3. It is required that department Training Officers (or other designee) maintain an up to date roster in the State CIS database and local Electronic Patient Care Reporting system. D. Clinical & Field Internship Clinical and field internship are available for individuals in the Harnett County EMS System. This internship can be done at Dunn Emergency Services, Harnett County EMS, Harnett Health System Hospitals or any other site that is pre - approved by the Medical Director and/or his/her designee. The internship will be determined based on the needs of the CE program, initial class requirements or individual need. The Medical Director will appoint a designee that will be the 33 contact for scheduling the internship at departments and at the local hospitals. The internships will be done when an individual enters the Harnett County EMS System, when personnel display problems with patient care, have been out of the system for 6 or more months and any others at the discretion of the Medical Director. The individual will have performance evaluation forms and will be assigned to an FTO /approved preceptor for evaluation. Individuals may also be evaluated in the clinical setting with the forms being completed by the nurse observing the skill(s). Once the performance requirement(s) are completed the individual will turn the packet into the EMS Systems Office (Harnett County EMS) for review. It will be determined if the individual can be released to function in the Harnett County EMS System after review by the Medical Director or his/her designee. The EMT- I/EMT -F will receive a written letter from the Medical Director confirming satisfactory /unsatisfactory completion of all requirements for the Harnett County EMS System. E. System Continuing Education Coordinator The Harnett County System Medical Director and or Harnett County System Administrator will appoint the Systems Continuing Education Coordinator. All continuing education schedules will be reviewed by the Systems Continuing Education Coordinator and forwarded to the Medical Director for approval. The Systems Continuing Education Coordinator is responsible for review of all educational components of the Harnett County EMS System. The Systems 34 Continuing Education Coordinator will conduct audits for all personnel in the Harnett County EMS System to ensure they continue to meet the educational and clinical components for the system. Any discrepancies noted will be reported to the Medical Director. The Systems Continuing Education Coordinator will assist department Training Officers as needed in developing their educational goals based on feedback from system EMS Care data and evaluation of patient outcomes and quality management peer reviews. As well, assuring requirements set by the Medical Director are implemented into the Education Standards. 35 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drivel 2707 Mail Service Center 1 Raleigh, NC 27603-20081 Phone: (919) 855 -3935 ) Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Coats Grove Fire & Rescue Office Number: (910) 897 -7575 Physical Address: 91 N. Mckinley Street Fax Number: (910) 891 -4174 City: Coats State: NC Provider Admin Contact: Jay Smith County: Harnett Zip: 27521 Title: Chief Mailing Address: PO Box 835 Office Number: (910) 897 -7575 City: Coats State: NC Mobile Number: (910) 984 -4705 County: Harnett Zip: 27521 Fax Number: (910) 891 -4174 PROPERTIES E -mail Address: district6dc @charter.net ir 'ce Level: EMT -Basic System Affiliation: Harnett Provider Number: 0430392 Provider Lic No: 1285 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below: CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16'" Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST FMS PTVM1ar 1 inanca Ranawal Fffariiva R/119014 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: BOA NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentiated personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: We provide 24 hour paid staff to staff the first duty crew ambulance. We supplement second duty crew with our roster of EMT volunteers. 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? • YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO 8 10A NCAC 13P .0204 (a)(5) Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: Ambulances are restocked after each call and the first out ambulance is checked for inventory daily, the second out ambulance is checked off every Monday and Thursday. Also mechanical checkoffs are performed and recorded. These records are kept for 3 years or 1 year after retirement of vehicle. 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 1508 -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We are currently entering and submitting all EMS calls on EMS Charts and is done on a routine basis 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Ambulances are restocked after each call. First out ambulance is checked daily and second out ambulance checked on Mondays and Thursdays 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Ambulances are sanitized and cleaned after each call and the first out ambulance is checked for maintenance daily and the second out is checked on Mondays and Thursdays. Vehicles are serviced at required intervals by local mechanic shop, Angier Tire and Auto in Angier, NC 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: All inventory with date expirations are examined before use and during the written checkoffs. Ambulances are kept in a temperature controlled bay when not on calls and all excess inventory is kept in a temperature controlled room prior to being put in service on the ambulance. EMS Provider License Renewal DHHSIDHSR/OEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 of 3 Effective 8/112014 10A NCAC 13P .0204 (a)(b) 10A NCAC 13P .0204 (a)(c) 10A NCAC 13P .0204 (a)(d) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level t or Level II Trauma Center as defined in Rules .0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effedive: 8/1/2014 PROVIDER NAME: Coats Grove Fire & Rescue Inc PROVIDER NUMBER: 0430392 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Ji41 5M1-1-4 Type /Print Name SYSTEM MEDICAL DIRECTOR pe /Print Name or �. C.\ I q 6'0 EMS SYSTEM ADMINISTRATOR Sign re I Sig to e C-/ Type /Print Nam *HOSPITAL ADMINISTRATOR Type /Print Name OPP Si • .i>!'u' Fixed Wing Provider: AYES e<O Date 1 Da 1/9 Date * *COUNTY MANAGER Type /Print Name Signature Date Signature Date * Hospital Administrator's signature is required for fixed wing providers. The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. If the county manager or system administrator has changed since last submission, a new letter from the county is required, EMS Provider License Renewal DHHS /DHSR /OEMs 4913 NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3 of 3 Effective 8/1/2014 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center 1 Raleigh, NC 27603 -2008 1 Phone: (919) 855 -3935 1 Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Erwin Fire Department & Rescue Squad Inc Office Number: (910) 897 -8151 Physical Address: 200 South 13th Street Fax Number: (910) 897 -7829 City: Erwin State: NC Provider Admin Contact: Ricky Blackmon County: Harnett Zip: 28339 Title: Chief Mailing Address: P.O. Box 36 Office Number: (910) 897 -8151 City: Erwwin State: NC Mobile Number: (910) 890 -2769 County: Harnett Zip: Fax Number: PROPERTIES E -mail Address: rblackmon @erwinfd.org Service Level: EMT -Basic System Affiliation: Harnett County lrovider Number: 0430456 Provider Lic No: 1286 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastem Regional Office of EMS Westem Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16th Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28813 -9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMS Provider License Renewal DHHSIDHSR/OEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 1 of 3 Effective 8112014 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 10A NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Hamett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: We provide 24/7 EMS coverage utilizing paid and volunteer personnel 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO • 8 10A NCAC 13P .0204 (a)(5) Provide systematic, pe iodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: Conduct daily inspection, cleaning, and routine repairs as needed, annual maintenance is conducted January or each year. Maintenance records are kept in a record book located in paid staff offices. Records are kept for life of vehicle 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 1508 -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We utilize EMS Charts software to collect and transmit data to premis. Data is stored on the county server and is transmitted on a routine bases by the county 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We use a daily check off sheet daily and after each callVehicles are clean 10A NCAC 13P .0204 (a)(7)(B) I for cleaning and mainta ning the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Vehicles are cleaned and inspected daily and after each call (when possible). Department provides equipment and chemicals to disinfect each unit. 10A NCAC 13P .0204 (aHl)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Check off sheets are used to inspect medications and equipment for expiration dates on a monthly basis. All vehicle bays are heated to maintain manufacturers recommendations in the winter and in summer moved inside and placed on unit when on call. Vehicles are left running to maintain temperatures. EMS Provider License Renewal DHHSIDHSRIOEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 of 3 Effective 8/1/2014 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. 10A NCAC 13P .0204 (a)(c) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level II Trauma Center as defined in Rules .0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. 10A NCAC 13P .0204 (a)(d) An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/1/2014 PROVIDER NAME: Erwin Fire Department & Rescue Squad Inc PROVIDER NUMBER: 0340456 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Ricky Blackmon Type/Print Name SYSTEM MEDICAL DIRECTOR Mark Glaser Type/Print Name ::MS SYSTEM ADMINISTRATOR Ricky Denning Type /Print Name *HOSPITAL ADMINISTRATOR ./ I. 4- Signature N,u()-e,\ Signature ,a Fixed Wing Provider: OYES ®NO Date nat're 12/9/2015 Date 12/9/2015 Date Type/Print Name * *COUNTY MANAGER Joseph Jeffries TypelPrint Name Signature Date Signature * Hospital Administrator's signature is required for fixed wing providers. Date ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county if the county manager or system administrator has changed since last submission, a new letter from the county is required. EMS Provider License Renewal DHHS/DHSR /GEMS 4913 NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3 of 3 Effective 8/1/2014 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drivel 2707 Mail Service Center 1 Raleigh, NC 27603 -2008 1 Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMD CENTER RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of Emergency Medical Dispatch (EMD) Centers. EMD Centers must be operational twenty -four (24) hours a day, seven (7) days a week. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the EMD Center Director, EMS System Administrator, System Medical Director, and County Manager (if applicable) are required. Renewals must be submitted to the appropriate regional EMS office indicated below. EMD Center Name: Harnett County Sheriff's Dept Office Number: (910) 893 -9111 Physical Address: 175 Bain St. Fax Number: (910) 814 -8314 City: Lillington State: NC Provider Admin Contact: Dianne M. Raynor County: Harnett Zip: 27546 Title: Communications Director Mailing Address: P.O. Box 399 Office Number: (910) 893 -0221 City: Lillington State: NC Mobile Number: County: Harnett Zip: 27546 Fax Number: (910) 814 -8314 PROVIDER PROPERTIES E -mail Address: draynor @harnett.org Provider Number: 0431035 System Affiliation: Harnett Renewals must be submitted to the appropriate regional office indicated below: CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16th Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMO Center Renewal OHHS /DHSR/OEMS 4917 SE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Clnret Ettectwe 8/172014 10A NCAC 13P .0401 COMPONENTS OF MEDICAL OVERSIGHT FOR EMS SYSTEMS SECTION .0400 - MEDICAL OVERSIGHT Each EMS System shall have the following components in place to assure medical oversight of the system: 10A NCAC 13P .0401(3) I for systems providing EMD service, an EMDPRS approved by the medical director. NOTE: Medical Director's signature is required on this application. 10A NCAC 13P .0403 RESPONSIBILITIES OF THE MEDICAL DIRECTOR. FOR EMS SYSTEMS 10A NCAC 13P .0403(a) The Medical Director for an EMS System is responsible for the following: 10A NCAC 13P .0403(a)(3) EMD programs, the establishment, approval, and annual updating of the EMDPRS. DATE OF LAST EMDPRS REVIEW: 8/1/2015 10A NCAC 13P .0407 REQUIREMENTS FOR EMERGENCY MEDICAL DISPATCH PRIORITY REFERENCE SYSTEM 10A NCAC 13P .0407(a) EMDPRS used by an EMD within an approved EMD program shall: 10A NCAC 13P .0407(a)(1) be approved by the OEMS Medical Director and meet or exceed the statewide standard for EMDPRS as defined by the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B-21.6, including subsequent amendments and editions. 10A NCAC 13P .0407(a)(2) not exceed the EMD scope of practice defined by the North Carolina Medical Board pursuant to G.S. 143 -514. 10A NCAC 13P .0407(b' An EMDPRS developed locally shall be reviewed and updated annually and submitted to the OEMS Medical Director for approval. Any change in the EMDPRS shall be submitted to the OEMS Medical Director for review and approval at least 30 days prior to the implementation of the change. (EXAMPLE: EMDPRS will be reviewed every January or as changes occur throughout the year.) EMDPRS CARD SET NAME: Priority Dispatch Corporation -EMD y p p VERSION NO: 122 EMDPRS LICENSE NO: 90 -10808 NOTE: 9 the EMDPRS is developed locally, please provide a complete copy of card set and assurance that the EMDPRS will be reviewed annually and submit to OEMS Medical Director for approval. VERIFY THE EMD ROSTER LISTED IN THE CREDENTIALING INFORMATION SYSTEM (CIS) IS CORRECT (if no, update in CIS): YES ONO BRIEFLY DESCRIBE THE EMD PROGRAM CONTINUING EDUCATION AND RECREDENTIALING REQUIREMENTS TO INCLUDE EDCUATIONAL INSTITUTION AND INSTRUCTOR INFORMATION: EMD requires 18 hours of mandatory annual continuing education. 12 of the 18 hours are conducted in a classroom setting. The remainder are obtained either, online through Richmond Community College, or industry specific professional publications. Instructors are state or nationally certified. Re- credentialing is submitted through Central Carolina Community College. VERIFY THE FCC CALL SIGN AND EXPIRATION DATE OF THE CENTER THAT WILL BE UTILIZING THE EMD PROGRAM IN THE CREDENTIALING INFORMATION SYSTEM (CIS) IS CORRECT (if no, update in CIS): O YES ONO FCC CALL SIGN: NC Viper EXPIRATION DATE: EMD Center Renewal DHHS /DHSRJOEMS 4917 NOTE: EMD Centers must have representation at Peer Review Committee Meetings. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Pan. ..( Effective 8/112014 EMD CENTER RENEWAL APPLICATION Effective: 8/1/2014 MD CENTER NAME: Harnett County Sheriffs Department ENDORSEMENTS PROVIDER NUMBER: 0431035 We, the undersigned, recommend this EMD Center for renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMD Center within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. EMD CENTER DIRECTOR Dianne M. Raynor Type/Print Name EMS SYSTEM ADMINISTRATOR Ricky G. Denning Type/Print Name SYSTEM MEDICAL DIRECTOR Dr. Mark Glaser ignature 14- n nature Type/Print Name *COUNTY MANAGER Joseph Jeffries \i\/\4 Signature z/v-A. /A4A, Date Date Type/Print Name Signature Date * The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. 1l the county manager or system administrator has changed since last submission, a new letter from the county is required. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST EMD Center Renewal Effective 811/2014 DHHS /DHSRJOEMS 4917 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center I Raleigh, NC 27603 -2008 1 Phone: (919) 855 -3935 1 Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Anderson Creek Emergency Services, Inc. Office Number: (910) 497 -0395 Physical Address: 6200 Overhills Road Fax Number: (910) 497 -3891 City: Spring Lake State: NC Provider Admin Contact: Elizabeth Rodriguez County: Harnett zip: 28390 Title: Assistant Chief, EMS Mailing Address: 6200 Overhills Road Office Number: (910) 497 -0395 City: Spring Lake State: NC Mobile Number. (910) 916 -3933 County: Harnett Zip: 28390 Fax Number: (910) 497 -3891 PROPERTIES E -mail Address: aces312chief @yahoo.com Service Level: EMT - Intermediate System Affiliation: Harnett County Provider Number 043592 Provider Lic No: 1114 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below: CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 161h Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 2 861 3 -921 3 Raleigh, NC 27699-2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMS Provider License Renewal OHMSJDHSR1OEMS 4913 SE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 1 of 3 Effective 8/112014 10A NCAC 13P . 0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 10A NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: Units are staffed 24/7 with part -time paid personnel. Units are always staffed with a minimum of an EMT Intermediate and Medical Responder. 1OA NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO • 10A NCAC 13P .0204 (a)(5) Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: Units are inspected and cleaned every morning and after every call. Oil changed every 5000 miles. All check -off sheets are maintained for one year and maintenance records for the life of the vehicle. 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We utilize EMS Charts software to collect patient data and that is submitted to PREMIS on a routine basis by the county. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Units are inspected daily with an approved check -off sheet and every drug and piece of equipment is checked for expiration date at the first of the month. 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Units are inspected each morning for cleanliness and units and equipment is decontaminated after each call. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Units are checked for expiration dates at the first of the month and replaced if expiring that month and all units have a shoreline equipped heater /air conditioner to maintain drug temperature. Units are left running while on calls and at the hospital to maintain temp. within specifications. EMS Provider License Renewal DHHSJDHSRIOEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2of3 Effective 611/2014 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. 10A NCAC 13P .0204 (a)(c) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level II Trauma Center as defined in Rules 0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. 10A NCAC 13P .0204 (a)(d) An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/1/2014 PROVIDER NAME: Anderson Creek Emergency Services, Inc. PROVIDER NUMBER: 043592 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Robert J. Wilson /Chief Type/Print Name SYSTEM M DICAL DIRECTOR l Type/Print Name EMS SYSTEM ADMINISTRATOR r t) 1 ,y Type /Print vhe `HOSPITAL ADMINISTRATOR Signature Signature Fixed Wing Provider: OYES ONO /0- 22-/5 Date Dati 4 Type/Print Name "'COUNTY MANAGER Signature Date Type/Prrnt Name Signature Date * Hospital Administrator's signature is required for fixed wing providers. 'rih The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. if the county manager or system administrator has changed since last submission, a new letter from the county is required. EMS Provider License Renewal OHHSIOHSRIOEMS 4913 NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3of3 Effective 811/2014 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center 1 Raleigh, NC 27603 -2008 I Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 811/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Dunn Emergency Services, Inc. Office Number: (910) 892 -1211 Physical Address: 101 W. Cumberland Street Fax Number: (910) 892 -7777 City: Dunn State: NC ProviderAdmin Contact: Gary Whitman County: Harnett Zip: 28334 Title: Chief /President Mailing Address: PO Box 203 Office Number: (910) 892 -1211 City: Dunn State: NC Mobile Number: (910) 263 -0278 County: Harnett Zip: 28335 Fax Number: (910) 892 -7777 PROPERTIES Email Address: drSchief @nc.rr.corn Service Level: EMT- Paramedic System Affiliation: Harnett County Provider Number: 0430141 Provider Lie No: 1113 License Exp. Date: Jan 31, 2016 Renewals muss be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below: CENTRAL, Central Regional Office of EMS EASTERN WESTERN Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive. Suite 7 3305 16th Avenue SE, Suite 302 2717 Mall Service Center Greenville, NC 27834 -6850 Conover. NC 28613-9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855.4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST EMS Provider Manse Renewal Effective 8192014 DHKSIDHSR/OEMS 4913 Page 1 of 3 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 10A NCAC 13P .0204 (a)(1) Be affiliated as defined In Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an app cation for a permit for any ambulance That will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: Career Paramedic provided 24/7 supplemented by part -time and volunteer staff 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate. or present written documentation of impending receipt of a franchise, from each county. In counties where there Is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? • YES NO • YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? 10A NCAC 13P .0204 (e)(bj Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of ail EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: All in service vehicles are inspected daily, cleaned after each response, maintenance is done on a scheduled basis on each vehicle. and vehicles are repaired as soon as possible after problems are reported. Records of inspection, maintenance and repairs are maintained at our facility for inspection. 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS date set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection,' incorporated by reference In accordance with G.S. 150B -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We are using EMS Charts software to collect and transmit data. Patient data is stored on EMS Charts' server and submitted by them. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Technicians are required to inspect and document the presence of the equipment and supplies required by the system and NCOEMS by using a check sheet provided by the department. Inspections are required daily. 10A NCAC 13P .0204 (a)(7)(8) 1 for cleaning and mainta ning the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Technicians are required to clean, decontaminate, and restock each vehicle after each response. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration dale and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Supplies and medications are inspected monthly for expiration dales. Supplies and medications whose expiration dates are approaching are removed from the vehicle and replaced. Medications are maintained at the manufacturers temperature specifications. EMS Prodder License Renewal DHHSIDHSR/OEMS 4913 BE PREPARED TO ('RESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 o13 Eflettive 911/2014 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rute, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rute .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. 10A NCAC 13P .0204 (a)(c) In addition to the general requirements detailed In Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level II Trauma Center as defined in Rules .0102(35) and (36) of this Subchapter designated by the OEMS Is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. IOA NCAC 13P .0204 (a)(tl) An EMS Provider may renew Its license by presenting documentation to the OEMS that the Provider meets the criteria found In Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/1 /2014 PROVIDER NAME: Dunn Emergency Services, Inc. PROVIDER NUMBER: 0430141 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowtedge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rutes of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Gary Whitman TypelPrint Name SYSTEM MEDICAL DIRECTOR Type /Print Name EMS SYSTEM ADMINISTRATOR Type/Prtn ante *HOSPITAL ADMINISTRATOR Signalur flied Wing Provider: OYES ONO Date /.;/R Dale Type /Print Name * *COUNTY MANAGER Signature Date Type/Print Name Signature Date * Hospital Administrator's signature is required for fixed wing providers. ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. if the county manager or system administrator has changed since last submission, a new letter from the county is required. NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. 13E PREPARED TO PRESEN i SUPPORTING DOCUMENTATION UPON REQUEST EMS Provider license Renewal Effective 811P2014 o I4S10 4SRtOEMS 4913 Page 3013 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center 1 Raleigh, NC 27603-20081 Phone: (919) 855-39351 Fax: (919) 733 -7021 EMS SYSTEM APPROVAL APPLICATION Effective: 8/1/2014 SECTION .0200 — EMS SYSTEMS 10A NCAC 13P..0201 EMS SYSTEM REQUIREMENTS 10A NCAC 13P .0201 (a) County govemments shall establish EMS Systems. Each EMS System shall have: 10A NCAC 13P .0201 (a)(1) a defined geographical service area for the EMS System. The minimum service area for an EMS System shall be one county. There may be multiple EMS Provider service areas within the service area of an EMS System. The highest level of care offered within any EMS Provider service area must be available to the citizens within that service area 24 hours per day; ENTER SYSTEM NAME: Harnett County BRIEF DESCRIPTION OF SYSTEM DELIVERY (include primary and secondary provider roles): Harnett County Is covered 24/7 by paramedic level provlders.We staff 13 Paramedic level ambulances 24/7.Hernett County ems,Dunn Emergency servlces,Anderson Creek Emergency services,Benhaven Emergency servlces,Boone Trail Emergency ServIces,BUles Creek Emergency Services,Coats Grove Fire Department,Erwin Fire Department & rescue work together to provide this service. 10A NCAC 13P .0201 (aj(2) a defined scope of practice for all EMS personnel, functioning in the EMS System, within the parameters set forth by the North Carolina Medical Board pursuant to G.S. 143 -514; VERIFY THE INFORMATION LISTED IN THE CREDENTIALING INFORMATION SYSTEM (CIS) IS CORRECT: 0 YES 0 NO 10A NCAC 13P .0201 (a)(3) written policies and procedures describing the dispatch, coordination and oversight of all responders that provide EMS care, specialty patient care skills and procedures as defined in Rule .0301(a)(4) of this Subchapter, and ambulance transport within the system; BRIEFLY DESCRIBE HOW EMS SYSTEM MEETS THIS REQUIREMENT: Our Harnett County EMS System utilizes policies and procedures from the 2012 NCCEP protocols document to meet the needs of our EMS System and approved by NCOEMS. 10A NCAC 13P .0201 (a)(4) at least one licensed EMS Provider, 10A NCAC 13P .0201 (a)(5) a listing of permitted ambulances to provide coverage to the service area 24 hours per day: 10A NCAC 13P .0201 (a)(6) personnel credentialed to perform within the scope of practice of the system and to staff the ambulance vehicles as required by G.S. 131E-158. There shall be a written plan for the use of credentialed EMS personnel for all practice settings used within the system; BRIEFLY DESCRIBE THE WRITTEN PLAN FOR THE USE OF CREDENTIALED EMS PERSONNEL FOR ALL PRACTICE SETTINGS USED WITHIN THE SYSTEM: Please refer to the attached Harnett County system plan. Section V page 20 & 21 10A NCAC 13P .0201 (a)(7) written policies and procedures specific to the utilization of the EMS System's EMS Care data for the daily and on -going management of all EMS System resources; BRIEFLY DESCRIBE HOW EMS SYSTEM MEETS THIS REQUIREMENT: All data is collected using EMS Charts and is transmitted to PreMis daily. All data is available to the system medical Director. Data is maintained for 12 years. 10A NCAC 13P .0201 (am) System written Infectious Disease Control Policy as defined in Rule .0102(33) of this Subchapter and written procedures which are approved by the EMS System medical director that address the cleansing and disinfecting of vehicles and equipment that are used to treat or transport patients; VERIFY THAT EMS SYSTEM HAS AN INFECTIOUS DISEASE CONTROL POLICY: O YES 0 NC) 10A NCAC 13P .0201 (a)(9) I a listing of facilities that will provide online medical direction for all EMS Providers operating within the EMS System; ENTER NAME OF FACILITY /FACILITIES THAT WILL PROVIDE ONLINE MEDICAL DIRECTION WITHIN THE EMS SYSTEM: Central Harnett Hospital Lillington Betsey Johnson Hospital Dunn System Approval Application DHHSIDHSRIOEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 1 of 8 Elrective 8(12014 10A NCAC 13P .0201 (a)(10) an EMS communication system that provides for: 10A NCAC 13P .0201 (a)(10)(A) public access using the emergency telephone number 9-1 -1 within the public dial telephone network as the primary method for the public to request emergency assistance. This number shall be connected to the emergency communications center or PSAP with immediate assistance available such that no caller will be instructed to hang up the telephone and dial another telephone number. A person calling for emergency assistance shall not be required to speak with more than two persons to request emergency medical assistance; BRIEFLY DESCRIBE HOW EMS SYSTEM MEETS THIS REQUIREMENT: Please see attached EMS system plan Section II page 7 10A NCAC 13P .0201 (a)(10)(B) 1 an emergency communications system operated by public safety tetecommunicators with training in the management of calls for medical assistance available 24 hours per day; DOES EMS SYSTEM PROVIDE EMD SERVICES? I a YES O NO 10A NCAC 13P .0201 (a)(10)(C) dispatch of the most appropriate emergency medical response unit or units to any caller's request for assistance. The dispatch of all response vehicles shall be in accordance with a written EMS System plan for the management and deployment of response vehicles including requests for mutual aid; and BRIEFLY DESCRIBE HOW EMS SYSTEM DISPATCHES EMERGENCY RESPONSE UNITS: 911 center uses the medical Priority Dispatch System version 12.2 to dispatch initial EMS calls and mutual aid EMS calls. The 911 center uses the call determinants to determine what resources respond to each call. 10A NCAC 13P .0201 (a)(10 )(0) two-way radio voice communications from within the defined service area to the emergency communications center or PSAP and to facilities where patents are routine y transported. The emergency communications system shall maintain all required FCC radio licenses or authorizations; VERIFY THE INFORMATION LISTED IN THE CREDENTIALING INFORMATION SYSTEM (CIS) IS CORRECT: () YES O NO 10A NCAC 13P .0201 (a)(11) I written policies and procedures for addressing the use of SCTP and Air Medical Programs within the system; BRIEFLY DESCRIBE EMS SYSTEM'S POLICY FOR ADDRESSING THE USE OF SCTP AND AIR MEDICAL PROGRAMS: Hamett EMS system utilizes the 2012 NCCEP Policies & procedures for air medical responses. .0A NCAC 13P .0201 (a)(12) a written continuing education program for all credentialed EMS personnel, under the direction of a System Continuing Education Coordinator, developed and modified based on feedback from system EMS Care data, review, and evaluation of patient outcomes and quality management peer reviews, that follows the guidelines of the: (A) "US DOT NHTSA First Responder Refresher: National Standard Curiculum" for MR personnel; (B) "US DOT NHTSA EMT -Basic Refresher. National Standard Curriculum" for EMT personnel; (C) "EMT -P and EMT -1 Continuing Education National Guidelines" for EMT -I and EMT -P personnel; and (D) "US DOT NHTSA Emergency Medical Dispatcher: National Standard Curriculum" for EMD personnel. BRIEFLY DESCRIBE HOW SYSTEM COORDINATOR MEETS THIS REQUIREMENT, HOW OFTEN THE PROGRAM IS REVIEWED, AND THE LOCATION OF THE CONTINUTING EDUCATION RECORDS: Please see attached EMS plan section VII page 26 -29 �'� VERIFY THE EMS SYSTEM CONTINUING EDUCATION COORDINATOR IS DESIGNATED IN THE (� 1 YES NO CREDENTIALING INFORMATION SYSTEM (CIS) (if no, update in CIS): �l 10A NCAC 13P .0201 (a)(13) written policies and procedures to address management of the EMS System that includes: 10A NCAC 13P .0201 (a)(13)(A) triage and transport of all acutely ill and injured patients with time -dependent or other specialized care issues including trauma, stroke, STEMI, burn, and pediatric patients that may require the by -pass of other licensed health care facilities and which are based upon the expanded clinical capabilities of the selected healthcare facilities; (NOTE: This requirement addressed though adoption of current NCCEP plans) 10A NCAC 13P .0201 (a)(13)(B) triage and transport of patients to facilities outside of the system; BRIEFLY DESCRIBE EMS SYSTEM'S POLICY FOR TRIAGE AND TRANSPORT OF PATIENTS TO FACILITIES OUTSIDE OF THE SYSTEM: Hamett County System routinely transports to facilities outside of the county per the triage and transport destination policies. 10A NCAC 13P .0201 (a)(13)(C) 1 arrangements for transporting patients to appropriate facilities when diversion or bypass plans are activated; BRIEFLY DESCRIBE EMS SYSTEM'S POLICY FOR TRANSPORTING PATIENTS WHEN DIVERSION OR BYPASS PLANS ARE ACTIVATED: Harnett health does riot have a diversion plan. System Approval Application DHHSIDHSRIOEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 of 8 Effective 8/1/2014 10A NCAC 13P .0201 (a)(13)(D) I reporting, monitoring, and establishing standards for system response times using data provided by the OEMS; BRIEFLY DESCRIBE EMS SYSTEM'S POLICY FOR MONITORING SYSTEM RESPONSE TIMES: Hamett County system utilizes data gathered from Premis as well as our reporting software to monitor response times throughout the county. Hamett County strives to have a 10 minute or Tess average response time. 10A NCAC 13P .0201 (a)(13)(E) I weekly updating of the SMARTT EMS Provider information; BRIEFLY DESCRIBE EMS SYSTEM'S POLICY FOR PROVIDING WEEKLY UPDATES OF THE SMARTT EMS PROVIDER INFORMATION: Updates are provided to the state by the System administrator and or his designe every Monday morning before 8:00 10A NCAC 13P .0201 (a)(13)(F) 1 a disaster plan; and VERIFY THAT EMS SYSTEM HAS A DISASTER PLAN: () YES V NO 10A NCAC 13P .0201 (a)(13)(G) 1 a mass - gathering plan; VERIFY THAT EMS SYSTEM HAS A MASS-GATHERING PLAN: I `) YES 0 NO 10A NCAC 13P .0201 (a)(14) I affiliation as defined in Rule .0102(4) of this Subchapter with the trauma RAC as required by Rule .1101(b) of this Subchapter, and SELECT NAME OF RAC AFFILIATION: Captial RAC 10A NCAC 13P .0201 (a)(15) medical oversight as required by Section .0400 of this Subchapter. 10A NCAC 13P .0201 (b) An application to establish an EMS System shall be submitted by the county to the OEMS for review. When the system is comprised of more than one county, only one application shall be submitted. The proposal shall demonstrate that the system meets the requirements in Paragraph (a) of this Rule. System approval shall be granted for a period of six years. Systems shall apply to OEMS for reapproval. 10A NCAC 13P .0203 SPECIAL SITUATIONS (For Informational Purposes Only) Upon application of citizens in North Carolina, the North Carolina Medical Care Commission shall approve the fumishing and providing of programs within the scope of practice of EMD, EMT, EMT -I, or EMT -P in North Carolina by persons who have been approved to provide these services by an agency of a state adjoining North Carolina or federal jurisdiction. This approval shall be granted where the North Carolina Medical Care Commission concludes that the requirements enumerated in Rule .0201 of this Subchapter cannot be reasonably obtained by reason of lack of geographical access. 10A NCAC 13P .0401 COMPONENTS OF MEDICAL OVERSIGHT FOR EMS SYSTEMS Each EMS System shall have the following components in place to assure medical oversight of the system: 10A NCAC 13P .0401 (1) a medical director for adult and pediatric patients appointed, either directly or by written delegation, by the county responsible for establishing the EMS System. Systems may elect to appoint one or more assistant medical directors. The medical director and assistant medical directors shall meet the criteria defined in the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B-21.6, including subsequent amendments and editions. (NOTE: Medical and Assistant Medical Director, if applicable, must be designated in Credentialing Information System. Any changes to medical direction must be submitted to OEMS for approval) 10A NCAC 13P .0401 (2) written treatment protocols for adult and pediatric patients for use by EMS personnel; 10A NCAC 13P .0401 (3) for systems providing EMD service, an EMDPRS approved by the medical director; (NOTE: See EMD program approval) 10A NCAC 13P .0401 (4) an EMS Peer Review Committee; and 10A NCAC 13P .0401 (5) written procedures for use by EMS personnel to obtain on -line medical direction. On -line medical direction shall: (a) be restricted to medical orders that fall within the scope of practice of the EMS personnel and within the scope of approved system treatment protocols; (b) be provided only by a physician, MICN, EMS -NP, or EMS -PA. Only physicians may deviate from written treatment protocols; and (c) be provided by a system of two-way voice communication that can be maintained throughout the treatment and disposition of the patient. BRIEFLY DESCRIBE EMS SYSTEM'S WRITTEN PROCEDURES TO OBTAIN ON -LINE MEDICAL DIRECTION: Please see attached EMS Plan section 111 page 17 System Approval Application DHHS/DHSR /OEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3of8 Effective 8/10014 10A NCAC 13P .0403 RESPONSIBILITIES OF THE MEDICAL DIRECTOR FOR EMS SYSTEMS 10A NCAC 13P .0403 (a) The Medical Director for an EMS System is responsible for the following: 10A NCAC 13P .0403 (a)(1) ensuring that medical control is available 24 hours a day; RIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR ENSURES THAT MEDICAL CONTROL IS AVAILABLE 24 HOURS A DAY: Please see EMS Plan attached section III page 17 10A NCAC 13P .0403 (a)(2) the establishment, approval and annual updating of adult and pediatric treatment protocols; 10A NCAC 13P .0403 (a)(3) EMD programs, the establishment, approval, and annual updating of the EMDPRS; 10A NCAC 13P .0403 (a)(4) medical supervision of the selection, system orientation, continuing education and performance of all EMS personnel; BRIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR MEETS THIS REQUIREMENT: Please see attached EMS Plan section V page 20 & 21 10A NCAC 13P .0403 (a)(5) medical supervision of a scope of practice performance evaluation for all EMS personnel in the system based on the treatment protocols for the system; BRIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR MEETS THIS REQUIREMENT: Please see attached EMS Plan section V page 21 10A NCAC 13P .0403 (a)(6) i the medical review of the care provided to patients; BRIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR MEETS THIS REQUIREMENT: Please see attached EMS System Plan section III pagel4 &15 10A NCAC 13P -0403 (a)(T) providing guidance regarding decisions about the equipment, medical supplies, and medications that will be canned on all ambulances and EMS nontransporting vehicles operating within the system; BRIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR MEETS THIS REQUIREMENT: Our EMS System Peer Review committee will review current practice and provide guidance regarding the equipment,supplies,and medications carried in our system. 10A NCAC 13P .0403 (a)(8) keeping the care provided up to date with current medical practice; and 10A NCAC 13P .04103 (a)(9) Developing and implementing an orientation plain for all hospitals within the EMS system that use MICN, EMS-NIP, or EMS-PA personnel to provide on -line medical direction to EMS personnel, which includes: (A) a discussion of all EMS System treatment protocols and procedures; (B) an explanation of the specific scope of practice for credentialed EMS personnel, as authorized by the approved EMS System treatment protocols as required by Rule .0405 of this Section; (C) a discussion of all practice settings within the EMS System and how scope of practice may vary in each setting; (0) a mechanism to assess the ability to effectively use EMS System communications equipment including hospital and prehospital devices, EMS communication protocols, and communications contingency plans as related to on -line medical direction; and (E) the successful completion of a scope of practice performance evaluation which verifies competency in Parts (A) through (D) of this Subparagraph and which is administered under the direction of the medical director. BRIEFLY DESCRIBE HOW EMS SYSTEM MEDICAL DIRECTOR MEETS THIS REQUIREMENT, IF APPLICABLE: Please see attached EMS Plan section III page 17 10A NCAC 13P .0403 (b) Any tasks related to Paragraph (a) of this Rule may be completed, through written delegation, by assisting physicians. physician assistants, nurse practitioners, registered nurses, EMDs, or EMT -Ps. DOES EMS SYSTEM HAVE WRITTEN DELEGATION TO PERFORM ANY TASKS RELATED TO PARAGRAPH (a) OF THIS RULE? O YES O NO IF YES, INDICATE POSITION OF PERSON RESPONSIBLE: 10A NCAC 13P .0403 (c) The Medical Director may suspend temporarily, pending due process review, any EMS personnel from further participation in the EMS System when it is determined the activities or medical care rendered by such personnel are detrimental to the care of the patient, constitute unprofessional conduct, or result in non - compliance with credentiating requirements. System Approval Application DHHS/DHSR/OEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Pape 4 of 8 Effective 8/112014 Please see attached ENS Plan section II pagel4 BRIEFLY DESCRIBE EMS SYSTEM MEDICAL DIRECTOR'S PROCESS TO MEET THIS REQUIREMENT: 10A NCAC 13P .0405 REQUIREMENTS FOR ADULT AND PEDIATRIC TREATMENT PROTOCOLS FOR EMS SYSTEMS (For Informational Purposes Only) 10A NCAC 13P .0405 (a) Treatment Protocols used in EMS Systems shall: 10A NCAC 131' .0405 (a)(1) Be adopted in their original form from the standard adult and pediatric treatment protocols as defined in the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B -21.6, including subsequent amendments and editions. 10A NCAC 13P .0405 (a)(2) Not contain medical procedures, medications, or intravenous fluids that exceed the scope of practice defined by the North Carolina Medical Board pursuant to G.S. 143 -514 for the level of care offered in the EMS System and any other applicable health care licensing board. iDA NCAC 13P .0405 (b) Individual adult and pediatric treatment protocols may be modified locally by EMS Systems if there is a change in a specific protocol which will optimize care within the local community which adds additional medications or medical procedures, or rearranges the order of care provided in the protocol contained within the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection" as described in Paragraph (a) of this Rule. Additional written Treatment Protocols may be developed by any EMS System in addition to the required protocols contained within the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection" as required by the EMS System. All North Carolina College of Emergency Physicians Policies and Procedures must be included and may be modified at the local level. All EMS System Treatment Protocols which have been added or changed by the EMS System shall be submitted to the OEMS Medical Director for review and approval at least 30 days prior to the implementation of the change. 10A NCAC 13P .0407 REQUIREMENTS FOR EMERGENCY MEDICAL DISPATCH PRIORITY REFERENCE SYSTEM (For Informational Purposes Only) 10A NCAC 13P .0407 (a) EMDPRS used by an EMD within an approved EMD program shall: 10A NCAC 131' .0407 (a)(1) be approved by the OEMS Medical Director and meet or exceed the statewide standard for EMDPRS as defined by the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B -21.6, including subsequent amendments and editions. 10A NCAC 13P .0407 (a)(2) not exceed the EMD scope of practice defined by the North Carolina Medical Board pursuant to G.S. 143 -514. 10A NCAC 13P .0407 (b) An EMDPRS developed locally shall be reviewed and updated annually and submitted to the OEMS Medical Director for approval. Any change in the EMDPRS shall be submitted to the OEMS Medical Director for review and approval at least 30 days prior to the implementation of the change. 10A NCAC 13P .0408 EMS PEER REVIEW COMMITTEE FOR EMS SYSTEMS The EMS Peer Review Committee for an EMS System shall: 10A NCAC 13P .0408 (1) I be composed of membership as defined in G.S. 131E- 155(6b). LIST OF COMMITTEE MEMBERS BY POSITION: Please see attached EMS Plan section III page 14 10A NCAC 13P .0408 (2) I appoint a physician as chairperson; DOES EMS SYSTEM MEDICAL DIRECTOR SERVE AS CHAIRPERSON: I `) YES 0 NO IF NO, PLEASE EXPLAIN: 10A NCAC 13P .0408 (3) I meet at least quarterly; IDENTIFY THE EMS SYSTEM QUARTERLY MEETINGS SCHEDULE: The system quarterly meetings are held the month following the end of the quarter. 70A NCAC 13P .0408 (4) use information gained from the analysis of system data submitted to the OEMS to evaluate the ongoing quality of patient care and medical direction within the system; System Approval Application DHHS/DHSR /OEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 5 of Effective 8/1/2014 BRIEFLY DESCRIBE HOW EMS SYSTEM USES DATA ANALYSIS TO EVALUATE PATIENT CARE AND MEDICAL DIRECTION: Data received from premis as well as 100 % peer review of patient care reports and imput from our Peer Review Committee, will help us to evaluate ongoing quality of patient care in Harnett County 10A NCAC 13P .0408 (5) use information gained from the analysis of system data submitted to the OEMS to make recommendations regarding the content of continuing education programs for all EMS personnel functioning within the EMS system; BRIEFLY DESCRIBE HOW EMS SYSTEM USES DATA ANALYSIS TO MAKE RECOMMENDATIONS FOR CONTINUING EDUCATION PROGRAMS: Hamett County will utlize system data as well as recommendations from the Peer Review Committee and imput from our Medical Director to enhance our education program. 10A NCAC 13P .0408 (6) I review adult and pediatric treatment protocols of the EMS System and make recommendations to the medical director for changes; BRIEFLY DESCRIBE HOW EMS SYSTEM MEETS THIS REQUIREMENT TO INCLUDE HOW OFTEN THE PROTOCOLS ARE REVIEWED: The EMS System protocols are developed locally following the NCCEP document guidelines. There is a designated Protocol Committee that meets every six months of the year or on an as needed basis. At that time protocols are reviewed and changes made, as needed, and submitted for review by the Peer Review Quality Management Committee. 10A NCAC 13P .0408 (7) establish and implement a written procedure to guarantee due process reviews for EMS personnel temporarily suspended by the medical director; 10A NCAC 13P .0408 (8) record and maintain minutes of committee meetings throughout the approval period of the EMS System; BRIEFLY DESCRIBE HOW EMS SYSTEM RECORDS AND MAINTAINS MEETING MINUTES: Minutes of the Peer Review Performance Subcommittee meeting will be maintained and regarded `confidential. "The Peer Review Quality Management Committee meeting minutes will be maintained by the EMS system and maintained at the department designated by the Medical Director. That location is Harnett County EMS. All documents and meeting minutes of all committees are considered confidential and can only be reviewed by committee members. 10A NCAC 13P .0408 (9) establish and implement EMS system performance improvement guidelines that meet or exceed the statewide standard as defined by the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B-21.6, including subsequent amendments and editions. 10A NCAC 13P .0408 (10) adopt written guidelines that address: (a) structure of committee membership; (b) appointment of committee officers; (c) appointment of committee members; (d) length of terms of committee members; (e) frequency of attendance of committee members; (t) establishment of a quorum for conducting business; and (g) confidentiality of medical records and personnel issues. BRIEFLY DESCRIBE EMS SYSTEM'S WRITTEN GUIDELINES TO MEET THIS REQUIREMENT: Please see attached EMS Plan section III page 14 -16 10A NCAC 13P .0506 PRACTICE SETTINGS FOR EMS PERSONNEL 10A NCAC 13P .0506 Credentialed EMS Personnel may function in the following practice settings in accordance with the protocols approved by the medical director of the EMS System or Specialty Care Transport Program with which they are affiliated, and by the OEMS: (1) at the location of a physiological or psychological illness or injury including transportation to an appropriate treatment facility if required; (2) at public or community health facilities in conjunction with public and community health initiatives; (3) in hospitals and clinics; (4) in residences, facilities, or other locations as part of wellness or injury prevention initiatives within the community and the public health system; and (5) al mass gatherings or special events. INDICATE SETTINGS WITHIN YOUR EMS SYSTEM (check all that apply): IN Mobile Integrated Healthcare ® Urban Search and Rescue ® High Angle Rescue • NTPS In Wildemess Rescue _ Swift Water Rescue I♦ Tactical Team • Air Medical • Medical Evacuation Bus • Bomb Squad il Ambulance Strike Team III Specialty Care System Approval Application DHHS/DHSR/OEMS 4912 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 6 of 8 Effective 8/1/2014 EMS SYSTEM APPROVAL APPLICATION Effective: 8/1/2014 EMS SYSTEM NAME: Hamett County ENDORSEMENTS We, the undersigned, recommend this EMS System for approval by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. SYSTEM MEDICAL DIRECTOR Mark Glaser TypelPrint Name EMS SYSTEM ADMINISTRATOR Ricky Denning Type/Print Name COUNTY MANAGER Joseph Jeffries Signature XI/ Signature Date Date Type/Print Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date QLicensed Agency Non - licensed Agency Type/Print Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date OLicensed Agency O Non - licensed Agency ,'ypelPrint Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date 0 Licensed Agency © Non - Licensed Agency Type/Print Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date OLicensed Agency a Non - licensed Agency Type/Print Name Signature Date PROVIDER ADMINISTRATOR / AGENCY NAME: O Licensed Agency O Non - licensed Agency Type /Print Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date QLicensed Agency 0 Non - licensed Agency Type /Print Name PROVIDER ADMINISTRATOR / AGENCY NAME: Signature Date ®Licensed Agency 0 Non - licensed Agency Type /Print Name Signature Date SE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST System Approval Application Effective 8/1/2014 DHHS/DHSR /OEMS 4912 Page 7of8 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drivel 2707 Mail Service Center I Raleigh, NC 27603 -2008 I Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Harnett County EMS Office Number (910) 893 -7563 Physical Address: 1005 Edwards bROTHERS dRIVE Fax Number: (910) 814 -2570 City: Lillington State: NC Provider Admin Contact: Ricky Denning County: Harnett Zip: 27504 Title: EMS Divsion Chief Mailing Address: P.O. Box 370 Office Number: (910) 893 -7563 City: Lillington state: NC Mobile Number: (910) 984 -6283 County: Harnett Zip: 27504 Fax Number: (910) 814 -2570 PROPERTIES E -mail Address: rdenning CYiharnett,org Service Level: EMT- Paramedic System Affiliation: Harnett County ovider Number: 0430604 Provider Lic No: 1115 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastem Regional Office of EMS Westem Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16th Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMS Provider License Renewal DHHS/DHSR/OEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 1 of 3 Effective 8/1/2014 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 10A NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Hamett County 10A NCAC 13P .0204 (a)(2) Present an application fora permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: Harnett County EMS employees 40 Full time Paramedics, 12 Intermediate/Basics and 74 part time employees to cover our response area 24/7. 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO • 10A NCAC 13P .0204 (a)(5) Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: Units are inspected daily at shift change. Units are serviced every 5000 miles. When repairs are needed they are done either at the county garage or a local independent certified mechanic. 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 1506 -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Hamett County EMS utilizes EMS Charts for its reporting software. Data collected is submitted on a regular bases. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: A list of required medications and supplies is set by our Medical Director and a daily check off sheet is filled out to ensure proper quantities on each unit. 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Units are inspected and cleaned on a daily bases at the beginning of every shift. Cleaning supplies are furnished as well as disinfectant to kill germs. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Medications and equipment with expiration dates are checked on a monthly base and replaced prior to them expiring. Medications are temperature controlled by leaving the unit running when temps are either to cold or to hot . When in quarters our bags are removed from units and placed inside . EMS Provider License Renewal DHHSIDHSR /OEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 of 3 Effective 8/1/2014 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. 10A NCAC 13P .0204 (a)(c) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level II Trauma Center as defined in Rules .0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. 10A NCAC 13P .0204 (a)(d) An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/1/2014 PROVIDER NAME: Harnett County EMS 0430604 PROVIDER NUMBER: ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Ricky Denning Type/Print Name SYSTEM MEDICAL DIRECTOR Mark Glaser Type /Print Name .MS SYSTEM ADMINISTRATOR Ricky Denning Type /Print Name „Xi Signature *HOSPITAL ADMINISTRATOR Signature Signature Fixed Wing Provider: AYES ONO t/t/9 Da Da Date Type /Print Name * *COUNTY MANAGER Joseph Jeffries TypelPrint Name Signature Date Signature * Hospital Administrator's signature is required for fixed wing providers. Date ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. If the county manager or system administrator has changed since last submission, a new letter fiom the county is required. EMS Provider License Renewal DHHS/DHSR /OEMS 4913 NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems, BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3 013 Effective 8112014 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center I Raleigh, NC 27603 -2008 I Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty 130) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Buies Creek Rural Fire Department INC. Office Number: (910) 893 -4327 Physical Address: 112 Marshbanks St Fax Number: (910) 893 -8475 City: Lillington State: NC Provider Admin Contact: Justin Riewestahl County: Harnett zip: 27546 Title: Chief of Department Mailing Address: P.O. Box 447 Office Number: (910) 893 -4327 City: Buies Creek State: NC Mobile Number: (919) 337 -8018 County: Harnett Zip: 27506 Fax Number: (910) 893 -8475 PROPERTIES E-mail Address: chief @buiescreekfirerescue.org S- -ce Level: EMT -Basic System Affiliation: Harnett County EMS Pruvider Number: 0431 053 Provider Lic No: 1544 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below: CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16th Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh, NC 27699 -2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST FMS Pmvirinr 1 irvnw RAnnwal Fffarlivw R/1/21114 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 1 OA NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; 1TER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E -156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: We provide EMS coverage 24 hrs a day, 7 days a week by utilizing paid and volunteer duty crew staff. We have a minimum of EMT -B and MR on every crew. 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO ■ 8 10A NCAC 13P .0204 (a) (5) Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: We check ambulances daily and clean /disinfect after each response. We utilize certified mechanics to perform routine maintenance on our vehicles. We keep all records for the life of the vehicles. 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 1508 -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We are presently utilizing EMS charts software to capture EMS data and its submitted to the state on routine basis by Hamett county on our behalf. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We inspect the ambulances daily and after each call to restock used items. 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESC RIBE HOW EMS PROVIDER MEETS RIB REQUIREMENT: The ambulances are checked for maintenance problems on a daily basis. We clean /disinfect ambulances after each call. We inspect the ambulances and check the equipment stock after each call to maintain readiness. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: We maintain climate control of our ambulances in the station. On our EMS incidents we keep operational with heat or AC operational to maintain manufacturer's specifications on medications. The medications are checked at the beginning of each month to ensure expiring drugs are removed and replaced. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST FMS Pmvi,1 r 1 iranaw Ranawwl Ffffw*ivn R1117f11d 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level II Trauma Center as defined in Rules 10A NCAC 13P .0204 (a)(c) 0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. 10A NCAC 13P .0204 (a)(d) An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/112014 Buies Creek Rural Fire Department INC. PROVIDER NAME: PROVIDER NUMBER: 0431053 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Justin Riewestahl Type/Print Name SYSTEM MEDICAL DIRECTOR Mark Glaser 'rint Name Fixed Wing Provider: OYES ONO /1-/ / 6 // Date EMS SYSTEM ADMINISTRATOR Ricky Denning Type /Print Name *HOSPITAL ADMINISTRATOR Sign ture SigifSture Type/Print Name * *COUNTY MANAGER Joseph Jeffries Signature Date Type /Print Name Signature * Hospital Administrator's signature is required for fixed wing providers. Date ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county_ If the county manager or system administrator has changed since last submission, a new letter from the county is required. NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST FMC PrnvidRr 1 ifgncR RRnRWRI Ffflattliva All nn14 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive i 2707 Mail Service Center I Raleigh, NC 27603 -2008 I Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Benhaven Emergency Services, Inc. office Number: (919) 499 -9511 Physical Address: 4023 N. Carolina Highway 87 North Fax Number: (919) 498 -0188 City: Sanford State: NC Provider Admin Contact: RA Thomas County: Hamett zip: 27332 Title: Chief Mailing Address: P.O. Box 301 Office Number: (919) 499 -9511 City: Olivia State: NC Mobile Number: (919) 356 -5311 County: Harnett zip: 28368 Fax Number: (919) 499 -1569 PROPERTIES E -mail Address: athomas ©benhavenfirerescue.com Service Level: EMT- Intermediate System Affiliation: Harnett County Provider Number: 0430699 Provider Lic No: 1287 License Exp. Date: Jan 31, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below: CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastern Regional Office of EMS Western Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 161° Avenue SE. Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh. NC 27699-2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMS Provider License Renewal OHHSIDHSR/OEMS 4913 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 1 of 3 Effeclve 0 /1/2014 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13P .0204 {a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 10A NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system. ENTER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will furnish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: All members are required to submit a written application to include all certifications and credentials. Driving and criminal checks are completed by our agency. Certification and credential verifications are through transcripts and the State CIS System. 10A NCAC 13P .0204 {a}(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a current franchise to operate. or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of [his Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO • 8 10A NCAC 13P .0204 (a)(5) Provide systematic. pe iodic inspection. repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: All vehicles are on a preventative maintenance program provided by a local fleet maintenance facility. All service and repair records are maintained in our Administrative office. The patient compartment and interior spaces are cleaned in accordance with Infectious Control Standards. Deconed per s 10A NCAC 13P .0204 (a)(6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection." incorporated by reference in accordance with G.S. 150B -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: The system uses a county wide server with all squads using EMS CHARTS. The software is designed to cover all parameters as required by the State. We provide members with desktop units, mobile data collection, high speed internet and mobile air cards to facilitate the electronic submission. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Vehicles are stocked and inspected based on form EMS 4905 provided by NCOEMS. Vehicles are inspected for compliance at the beginning of each shift and after each call. Shift inspection forms are maintained in the Administrative office for at least one year. 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: All members are provided SOG's and job descriptions that outline how vehicles and equipment are to be cleaned and maintained. The squad maintains contracts for equipment that require a third party to service. Vehicles are maintained as outlined in Section 5 of this plan. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Any stocked item with an expiration date is inspected on the last day of the month for compliance. All units are stored in a climate controlled environment when not responding to calls. When out of stations departmental SOG's require the vehicle to maintain a controlled environment based on weather EMS Provider License Renewal OHHSIDHSR /GEMS 4913 SE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 2 of 3 Effective 8)12014 In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing 10A NCAC 13P .0204 (a)(b) affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) required to ensure the provision of peer review. medical director oversight and treatment protocol mainte In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing affiliation as defined in Rule .0102(4) of this Subchapter with a Level 1 or Level II Trauma Center 10A NCAC 13P .0204 (a)(c) .0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the Medical Care Commission exempts the Dare County EMS System from this Paragraph. An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. air medical services, of this Subchapter is narlce. air medical services, as defined in Rules peer review, medical County of Dare, the 10A NCAC 13P .0204 (a)(d) EMS PROVIDER LICENSE RENEWAL Effective 8/1 /2014 PROVIDER NAME: Benhaven Emergency Services, Inc. 0430699 PROVIDER NUMBER: ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the Slate of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR RA Thomas TypelPrint Name SYSTEM MEDICAL DIRECTOR veVi Type /Prir't Name \c' \r2_, ct Fixed Wing Provider: OYES 10/30/2015 Date ONO Signature EMS SYSTEM ADMINISTRATOR TypelPrint Name '4/ � r a *HOSPITAL ADMINISTRATOR Dat/y1/4, TypelPrint Name **COUNTY MANAGER Type /Print Name Signature Date Signature Date * Hospital Administrator's signature is required for fixed wing providers. ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. If the county manager or system administrator has changed since last submission, a new letter from the county is required. EMS Provider License Renewal —"NISR /GEMS 4913 NOTE: If a provider operates in multiple county EMS Systems, an Endorsements page must be completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST Page 3of3 Eileclive 8/1/2014 NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive 1 2707 Mail Service Center 1 Raleigh, NC 27603 -2008 I Phone: (919) 855 -3935 I Fax: (919) 733 -7021 EMS PROVIDER LICENSE RENEWAL APPLICATION Effective: 8/1/2014 This application is for renewal of a current EMS Provider License only. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the Provider Administrator, System Medical Director, EMS System Administrator, Hospital Administrator (for fixed -wing providers), and County Manager (if applicable) are required. Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. GENERAL INFORMATION Provider Name: Boone Trail Emergency Services, Inc. Office Number: (910) 893 -3750 Physical Address: 7016 US Hwy 421 North Fax Number: (910) 893 -5092 City: Lillington State: NC Provider Admin Contact: Tony Currin County: Harnett Zip: 27546 Title: Chief Mailing Address: PO Box 411 Office Number: (910) 893 -3750 City: Mamers State: NC Mobile Number: (910) 814 -7192 County: Harnett Zip: 27552 Fax Number: (910) 893 -5092 PROPERTIES E -mail Address: btes.harnett@yahoo.com 1 Service Level: EMT -Basic System Affiliation: Harnett County rovider Number: i 0430660 Provider Lic No: 1412 License Exp. Date: Jan 1, 2016 Renewals must be submitted at least thirty (30) days prior to expiration to the appropriate regional office indicated below. CENTRAL EASTERN WESTERN Central Regional Office of EMS Eastem Regional Office of EMS Westem Regional Office of EMS 801 Biggs Drive 404 St. Andrews Drive, Suite 7 3305 16"' Avenue SE, Suite 302 2717 Mail Service Center Greenville, NC 27834 -6850 Conover, NC 28613 -9213 Raleigh, NC 27699-2717 Office: (252) 355 -9026 Office: (828) 466 -5548 Office: (919) 855 -4678 Fax: (2525) 355 -9063 Fax: (828) 466 -5651 Fax: (919) 715 -0498 EMS Provider License Renewal OHHS/DHSR /DEMS 4913 BE. PREPARED TO PRESENT SUPPOi?T0'G DOC'.. /MENTf /ON !JPQi R.E i:EST Page 1 of 3 Effective 8/1/2014 10A NCAC 13P .0204 EMS PROVIDER LICENSE REQUIREMENTS 10A NCAC 13F .0204 (a) Any firm, corporation, agency, organization or association that provides emergency medical services shall be licensed as an EMS Provider by meeting and continuously maintaining the following criteria: 1 OA NCAC 13P .0204 (a)(1) Be affiliated as defined in Rule .0102(4) of this Subchapter with each EMS System where there is to be a physical base of operation or where the EMS Provider will provide point -to -point patient transport within the system; ENTER SYSTEM NAME: Harnett County 10A NCAC 13P .0204 (a)(2) Present an application for a permit for any ambulance that will be in service as required by G.S. 131E-156; 10A NCAC 13P .0204 (a)(3) Submit a written plan detailing how the EMS Provider will fumish credentialed personnel; BRIEFLY DESCRIBE HOW EMS PROVIDER WILL FURNISH CREDENTIALED PERSONNEL: Credentialed staff will be furnished through a combination of Paid and Volunteer staffing and credential status monitored through CIS. 10A NCAC 13P .0204 (a)(4) Where there are franchise ordinances pursuant to G.S 153A -250 in effect that cover the proposed service areas of each EMS system of operation, show the affiliation as defined in Rule .0102(4) of this Subchapter with each EMS System, as required by Subparagraph (a)(1) of this Rule, by being granted a cun-ent franchise to operate, or present written documentation of impending receipt of a franchise, from each county. In counties where there is no franchise ordinance in effect, present a signature from each EMS System representative authorizing the EMS Provider to affiliate as defined in Rule .0102(4) of this Subchapter and as required by Paragraph (a)(1) of this Rule; DOES COUNTY HAVE A FRANCHISE ORDINANCE? YES NO IF YES, IS FRANCHISE AGREEMENT GRANTED? • YES NO • 8 10A NCAC 13P .0204 (a)(5) Provide systematic, periodic inspection, repair, cleaning, and routine maintenance of all EMS responding ground vehicles and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT TO INCLUDE HOW UNITS ARE CLEANED, MAINTAINED, AND REPAIRED: Units are checked off on a daily basis which includes cleaning exterior and interior. Daily cleaning with disinfectant. Crews maintain cleanliness of unit after each call. Routine maintenance and unscheduled repairs are provided through 2 local service locations. 10A NCAC 13P .0204 (ax6) Collect and within 24 hours electronically submit to the OEMS EMS Care data that uses the EMS data set and data dictionary as specified in "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B -21.6, including subsequent amendments and additions. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Patient care reports submitted utilizing EMS Charts. 10A NCAC 13P .0204 (a)(7) Develop and implement written operational protocols for the management of equipment, supplies and medications and maintain records available for inspection by the OEMS which verify compliance with this Subparagraph. These protocols shall include a methodology: 10A NCAC 13P .0204 (a)(7)(A) to assure that each vehicle contains the required equipment and supplies on each response; BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Units checked daily to comply with Harnett County approved Equipment, Supply and Medication supply matrix. 10A NCAC 13P .0204 (a)(7)(B) for cleaning and maintaining the equipment and vehicles; and BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Cleaned daily using appropriate cleaning solution and after each use. Stretcher maintenance contract in place. 10A NCAC 13P .0204 (a)(7)(C) to assure that supplies and medications are not used beyond the expiration date and stored in a temperature controlled atmosphere according to manufacturer's specifications. BRIEFLY DESCRIBE HOW EMS PROVIDER MEETS THIS REQUIREMENT: Unit is checked daily and an end of month check off is completed to ensure supplies in date. Unit is housed in temperature controlled bay when not in use. Units remain running for duration of call. EMS Provider License Renewal DHHS/DHSR /OEMS 4913 ?t: PREPARED TO PRESEI4`t SUPPOR Ti 4G 1X)C!,JMEN rATlOr4 UPON I2Ecp}ESST, Page 2 of 3 Effective 8/12014 10A NCAC 13P .0204 (a)(b) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing fixed -wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a hospital as defined in Rule .0102(30) of this Subchapter is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. 1OA NCAC 13P .0204 (a)(c) In addition to the general requirements detailed in Paragraph (a) of this Rule, if providing rotary-wing air medical services, affiliation as defined in Rule .0102(4) of this Subchapter with a Level I or Level 11 Trauma Center as defined in Rules .0102(35) and (36) of this Subchapter designated by the OEMS is required to ensure the provision of peer review, medical director oversight and treatment protocol maintenance. Due to the geographical barriers unique to the County of Dare, the Medical Care Commission exempts the Dare County EMS System from this Paragraph. 10A NCAC 13P .0204 (a)(d) An EMS Provider may renew its license by presenting documentation to the OEMS that the Provider meets the criteria found in Paragraphs (a) through (c) of this Rule. EMS PROVIDER LICENSE RENEWAL Effective: 8/1/2014 PROVIDER NAME: PROVIDER Trail Emergency Services, Inc. PROVIDER NUMBER: 0430660 ENDORSEMENTS We, the undersigned, recommend this EMS Provider for License Renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMS Provider within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. PROVIDER ADMINISTRATOR Tony Currin, Chief Type/Print Name SYSTEM MEDICAL DIRECTOR CA (g'gv EMS SYSTEM ADMINISTRATOR f �l SignaturE i \II\A Signature • / <2 C 4,17/7 TypelPrint Name 21/ Sig *HOSPITAL ADMINISTRATOR Fixed Wing Provider: OYES ONO in - ,Po - o/.' Date Da 2/9 Type /Print Name **COUNTY MANAGER Signature Date Type /Print Name Signature Date * Hospital Administrator's signature is required for fixed wing providers. ** The County Manager's signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. if the county manager or system administrator has changed since last submission, a new letter from the county is required. NOTE: if a provider operates in multiple county EMS Systems, an Endorsements page must he completed for each of the county EMS Systems. BE PREPARED TO PRESENT SUPPORTING DOC :UMENTATSON UPON REQUEST EMS Provider License Renewal Effective 8/112014 DHHSIDHSR /OEMS 4913 - Page 3 of 3 Board Meeting Agenda Item MEETING DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Reclassification and new position request REQUESTED BY: Jimmy Riddle, Emergency Services Director REQUEST: 1. Request new Fire Marshal position. The County Fire Marshal duties currently fall under the vacant Deputy Emergency Services Director's position. Due to the nature of the duties, and the increasing activity within the County, we would like to request that a new position, County Fire Marshal Grade 78, be added to the department. This position will also serve as the division supervisor. 2. Reclassification of job duties for the Deputy Emergency Services Director position (DESD). In direct correlation to the new position request, it is requested that the current vacant DESD job duties be reclassified to remove the duties of the Fire Marshal, and that new and broader duties be added. The additional duties will allow the job to function in a manner which will greater complement the Emergency Services Director's position. Additionally, it is also requested that this position be graded from a 79 to a Grade 80 (the Emergency Services Director's position is a grade 82). This request will allow the department a broader flexibility in meeting its long -range plan and staffing requirements. FINANCE OFFICER'S RECOMMENDATION: Yes COUNTY MANAGER'S RECOMMENDATION: C:\ Users\ gwheeler\AppData\Local\Microsoft\Windows \Temporary Internet Files\ Content .Outlook198RKKOE51Emergency Services New POsition.doc Page 1 of 1 EMERGENCY SERVICES DEPUTY DIRECTOR General Statement of Duties Performs management and professional work directing the emergency medical, emergency management, and fire marshal services for the County as assigned or in the absence of the Emergency Services Director. Distinguishing Features of the Class An employee in this class plans, develops, organizes and directs the activities of the emergency services for the County. Work involves budget preparation and administration, personnel staffing and training, equipment maintenance oversight, development and implementation of policies and procedures, legal issues, and regulatory management and compliance for the department. Work involves a broad scope of public contacts requiring facilitation skills, a variety of technical and detailed knowledge in the area of emergency medical services, emergency management, disasters, homeland security, and fire; and considerable independent initiative and judgment. The employee is subject to hazards in the emergency services work including working in both inside and outside environmental conditions, extreme temperatures, hazardous fumes, dusts, odors, mists, and gases and working in close quarters. Work may expose the employee to human blood or body fluids and thus the job is subject to the OSHA requirements on blood borne pathogens. Work is supervised by the Emergency Services Director and is evaluated through conferences, results of work, reports, and public feedback. Duties and Responsibilities Essential Duties and Tasks Plans, organizes, and directs the emergency preparations and response of the County; coordinates with state and local officials; responds to emergency situations and may assume command; writes and administers grants for EOC and emergency response equipment; provides public education and awareness programming; maintains EOC; ; chairs emergency planning committee. Coordinates emergency planning and response with a wide variety of federal, state, regional and local officials and agencies. Plans, organizes and directs the activities of emergency medical services department and staff; coordinates procedures and regulations with agencies served; assures maintenance of up to date procedures and protocols; research and implementation of new and revised protocols; insures proper quality control of documentation and medical response; insures proper training of staff; coordinates and monitors the maintenance of emergency medical facilities, vehicles, equipment, and materials. Develops plans for mitigation, response and recovery of all types of man -made or natural disasters, including national security, nuclear plant, weather, hazardous materials spills and others. Participates as necessary in the work of the Fire Marshal's office. Researches, recommends and obtains needed equipment; insures proper purchasing procedures are followed. Develops and recommends budget requests; handles purchasing of equipment, materials, and supplies; monitors and administers the approved budget; coordinates efforts for billing and collections. Identifies resources at the state and local levels that may be utilized in emergency situations. Develops and implements new programs, policies, standards, criteria, and procedures for existing medical services. Establishes and coordinates a Local Emergency Planning Committee. Handles personnel functions for staff including recruiting, training, disciplining, monitoring, and evaluating work; responds to complaints, questions, and information about the services; responds to major emergency incidents. Assures the maintenance and completion of records, reports, and other information required in the department. Assures compliance with laws, rules, and regulations such as OSHA, FCC, third party Emergency Services Director Page 2 standards, fire codes, other ordinances and federal or state legislation. Develops methods for evaluation of programs and systems designed to help with better resource management. Additional Job Duties Attends conferences, training classes, meetings and reads literature to remain current with new trends and development in the field. Performs related duties as required. Recruitment and Selection Guidelines Knowledges, Skills and Abilities Thorough knowledge of federal, state, and local laws, policies, procedures, and regulations pertaining to emergency medical, emergency management, communications, and other services. Thorough knowledge of emergency medical practices and procedures. Considerable knowledge of public management practices including planning, budgeting, purchasing, personnel, and related supervisory requirements. Considerable knowledge of fire properties, the principles and practices of fire suppression and prevention, and related laws and regulations and of OSHA requirements Ability to interpret, explain, and apply a wide variety of policies, procedures, and regulations. Ability to prepare reports and make effective public presentations. Ability to analyze situations and services and react quickly, effectively, and professionally in emergency situations and to use sound judgment and determine best options and decisions for handling emergency matters. Ability to plan and organize work to meet deadlines and governmental requirements. Ability to establish and maintain effective working relationships with law enforcement agencies, volunteer fire services, public officials, hospitals, schools, and general public. Ability to plan, supervise, monitor, and direct a department spread over multiple locations and functions. Ability to communicate effectively in oral and written forms. Physical Requirements Must be able to perform the physical life functions of climbing, balancing, stooping, kneeling, crouching, reaching, walking, pushing, pulling, lifting, fingering, talking, and hearing. Must be able to perform very heavy work exerting in excess of 100 pounds of force occasionally, and /or in excess of 50 pounds of force frequently, and /or in excess of 20 pounds of force constantly to move objects. Must possess visual acuity to prepare and analyze data and figures, perform accounting functions, operate a computer terminal, operate a motor vehicle, do extensive reading and use measurement devices. Desirable Education and Experience Graduation from college or university with a BA/BS degree in health services, public or business administration, or related field and considerable experience in emergency services including supervisory experience; or an equivalent combination of education and experience. Special Requirements Possession of a valid NC driver's license. Ability to obtain state certification in emergency management. Harnett County 2016 FIRE MARSHAL General Statement of Duties Performs administrative and supervisory work managing the fire suppression, prevention, investigations and inspections programs functions for the County. Distinguishing Features of the Class An employee in this class is responsible for the overall County fire inspection and safety function, and for assisting in overall emergency management planning and response.. Work involves conducting a fire prevention and inspection program to ensure compliance with State and local fire laws, codes, rules, and regulations. Work includes supervising inspections of commercial and retail establishments, schools, and health care facilities; supervising and conducting fire education and safety programs, fire investigations and training; and serving as liaison with the fire departments in the County. The employee is also responsible for assisting in developing and implementing emergency action plans in the event of natural and man -made disasters. Considerable independence and judgment are required in all aspects of the work, particularly in fire inspections. Considerable public contact requires that the employee exhibit tact and diplomacy in seeking compliance with fire laws, codes, rules, and regulations. The employee is subject to hazards associated with fire inspection, administrative, and firefighting work including working in both inside and outside environments, in extreme cold weather, and exposure to various hazards such as exposure to high heat, exposure to chemicals, and in the proximity to moving mechanical parts, electrical current, and working in high places. The employee is also exposed to atmospheric conditions and blood borne pathogens, and is sometimes required to wear a respirator, and may be required to work in close quarters. Work is performed under the general direction of the Emergency Services Director and is evaluated through observation, conferences, and written reports concerning the quality and effectiveness of work performed. Duties and Responsibilities Essential Duties and Tasks Directs the operation of the Fire Marshall's office including supervision of staff and program operations; supervises and participates in fire inspection, fire code enforcement, plans review and other technical functions. Participates in the planning and implementation of County -wide plans for multiple responses to natural or man -made disasters; works in the EOC to coordinate activities with local fire departments. responds to emergency incidents and conditions in the County and supervise operations or backs up staff in response activities. Evaluates and monitors the performance of volunteer fire agencies providing contract services to the citizens of the county; meets with officials appointed and elected to carry out fire and emergency response mitigation and assist them as needed to ensure they are meeting the needs of their respective communities and complying with state law and local guidelines, and with maintaining their state insurance protection grade. Assists Emergency Services Director on specialized projects, reports and activities; applies for grants and provides grant reporting. Manages, supervises and maintains software database program for County and statewide fire reporting; makes updates; works with departments on technical issues; compiles data for County reports and assists other agencies with data needs. Plans and conducts a program of reducing fire hazards by securing compliance with State and local laws, codes, rules, and regulations; enforces the State Building Codes related to fire prevention in Fire Marshal Page 2 the County. Participates in plan review including attending technical review committee meetings when needed; reviews plans for compliance with fire prevention codes and for meeting water supply needs for firefighting. Travels to all parts of the county at various hours to perform an evaluation of circumstances /causal relationships using scientific methods to determine the cause of fire. Develops, maintains and manages standard operating procedures and guidelines for office; manages budget. Advises local communities on the organizing of a volunteer fire Department and serves as a resource to fire departments in purchasing fire equipment. Additional Job Duties Attends lectures; studies manuals; participates in fire drills and learns modern firefighting techniques; attends training to maintain certifications and increase skills. Performs related duties as required. Recruitment and Selection Guidelines Knowledges, Skills, and Abilities Thorough knowledge of the types of industrial and commercial operations in the county and any related potential hazards. Thorough knowledge of the methods of readily ascertaining the presence of existing or potential fire hazards. Thorough knowledge of the laws, codes, regulations, principles and practices regarding fire prevention. Thorough knowledge of fire equipment operation and maintenance, and skill in its operation. Thorough knowledge of specialized fire database program and ability to use program to develop fire reports and data. Considerable knowledge of the cause and origins of fire and scientific detection principles. Skill in collaborative conflict resolution. Ability to read, interpret and apply a wide variety of codes, policies, procedures, and regulations. Ability to prepare reports and make effective public presentations. Ability to react quickly, effectively, and professionally in emergency situations. Ability to use sound judgment and determine best options and decisions for handling emergency matters. Ability to establish and maintain effective working relationships with law enforcement agencies, volunteer fire services, public officials, hospitals, schools, and general public. Ability to enforce codes and laws with firmness and fairness. Physical Requirements Must be able to physically perform the basic life operational functions of climbing, balancing, stooping, kneeling, crouching, crawling, reaching, standing, walking, pushing, pulling, lifting, fingering, grasping, feeling, talking, hearing, and perform repetitive motions. Must be able to perform very heavy work exerting in excess of 100 pounds of force occasionally, and 50 pounds of force frequently, and up to 20 pounds of force constantly. Must possess the visual acuity to prepare and analyze data, for extensive reading and work with figures; to operate a computer, to inspect fire sites, to use measuring devices, to operate a motor vehicle; and to determine accuracy and neatness of work . Fire Marshall Page 3 Desirable Education and Experience Completion of high school and fire inspection and prevention schools and advanced courses and seminars in fire service and emergency response activities, and considerable experience in the fire service and /or fire inspections; or an equivalent combination of education and experience. Prefer AS in Fire Protection Technology. Special Requirement Possession of a valid North Carolina driver's license. Possession of a level III Fire Code Inspector certification as required by the state to enforce volume V of the state building code. Possession of a Fire Investigator certification or equivalent. Harnett County 2008 Board Meeting Agenda Item MEETING DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Reclassification of two Heavy Equipment Operator positions - pay grade 63 to Solid Waste Crew Leader - pay grade 65 REQUESTED BY: Amanda L. Bader, County Engineer REQUEST: County Engineer requests the reclassification of two Heavy Equipment Operator positions, pay grade 63 to Solid Waste Crew Leaders, pay grade 65. The reason for this reclassification is to create a construction crew under the Solid Waste department. This crew will be responsible for ongoing construction at the landfill such as the Dunn -Erwin vertical expansion, Anderson Creek expansion, Sheriffs firing range and other County projects. This crew will operate independently and schedule projects, coordinate meetings with design engineers, coordinate third party construction testing, relocate construction equipment, stage equipment and materials, coordinate construction staking and maintain compliance with construction permitting including erosion control, stormwater, and DEQ requirments. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: C:\ Users \bblinson\AppData \Local \Microsoft \Windows \Temporary Internet Files \Content.Outlook \YSZDEOOQ \16 01 04 - BOC Agenda Request - Reclassifiation Heavy Equipment Operators.doc Page 1 of 2 Board Meeting Agenda Item MEETING DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Department Reorganization REQUESTED BY: Ira Hall, Director of Harnett County Information Technology REQUEST: With recent staff changes, the Information Technology Department is requesting a minor department reorganization to realign positions for our "succession plan" and provide more comprehensive support for the county's core infrastructure. I would like to: 1) transition the Applications Analyst position to the Systems Team and reduce the pay grade from 77 to 75. 2) increase the grade of the Systems Manager position from salary grade 77 to grade 78 to align this position to our succession plan 3) Change our Admin Assistant title to Admin Tech and increased one grade level from 63 to 64 that will correspond with newly assigned technical duties. These transitions will not change the current I.T. Department budget. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: C:\ Users \gwheeler\AppData\ Local\ Microsoft\Windows \Temporary Internet Files\ Content. Outlook\98RKKOE5 \agendaform2016 (002).doc 1 of 1 Page E t Q cn CO a) O O C N 2 U ti c a Q a3 O ^^ LL i CU GRADE: 76 HARNETT COUNTY JOB DESCRIPTION JOB TITLE: Senior Information Systems Specialist Position Number: FLSA- Status: Non - Exempt GENERAL STATEMENT OF JOB An employee in this class is responsible for troubleshooting and resolving server, PC, and network hardware and software problems across all county departments. On -call maybe required for after -hours support of these services. Duties include tasks such as installing, maintaining and supporting computers, servers, firewalls, remote user connections, and networks in all departments, municipalities and agencies supported by the County. Duties also include providing technical assistance and troubleshooting end -user problems; maintaining phone, voice and communications systems; maintaining specialized equipment used in field environments; performing and maintaining data backups; installing and configuring personal computers and peripherals; maintaining and upgrading of network components; performing set -up for network, phone and e-mail accounts; recommending equipment and software solutions for County departments' needs; staffing the Emergency Operations Center as needed; and working as a part of a team on special technology projects. Work requires specialized database analysis and reporting. Work also requires a high level of technical knowledge on hardware and software applications, understanding of networks, and an understanding of computer programming applications. Work is performed under supervision and is reviewed through conferences, observation, and review of project progress and completion. SPECIFIC DUTIES AND RESPONSIBILITIES • Supports a variety of departments, including Public Utilities, Library, Sheriff, EMS, Fire Marshal, and Emergency Management/EOC. May provide on -call technical support after- hours, weekends, and holidays. • Installs, repairs, patches, and configures workstations, servers, switches, routers, firewalls, and phone system. • Resolves equipment and network failures. • Assists departmental users with hardware, software, and server problems. • Provides support for SQL issues, network and phone issues, including support for the municipalities that use County supported applications. • Serves as network administrator in assigned departments. • Creates and maintains network user and email accoints. • Conducts research and makes recommendations on upgrades and new solutions that will help streamline a department. • Meets with vendors and users about potential upgrades, new software/hardware. • Attends training when applicable to help keep up with growing technology needs of the County. • Staffs the Emergency Operations Center when in operation to assure all equipment and systems operate; troubleshoots problems as needed. • Maintains awareness of state and federal rules and regulations affecting the transmission of medical and law enforcement data. • Maintains a variety of specialized databases supporting law enforcement and emergency medical operations. • Conducts data back -up, software installation and system configurations for users. • Works with a variety of equipment used in office and field locations. • Performs maintenance and upgrades for computer and network components. • Performs server maintenance and configurations. • Performs specialized troubleshooting of software issues. • Travels to worksites to perform customer support services. • Instructs and trains users on the system's applications. ADDITIONAL JOB FUNCTIONS Performs other related work as required. MINIMUM TRAINING AND EXPERIENCE A Bachelor's degree in information technology or related field and at least four years' experience or an equivalent combination of education and experience. Supplemental qualifications or information: Possession of a valid North Carolina driver's license Certifications such as Microsoft, Cisco, CompTIA GRADE: 64 HARNETT COUNTY JOB DESCRIPTION JOB TITLE: IT ADMINISTRATIVE TECHNICIAN Position Number: FLSA- Status: Non - Exempt GENERAL STATEMENT OF JOB Under minimum guidance and supervision, this position performs technical, administrative and research work for the Harnett County IT Department. Work involves various duties for the IT Department such as receiving requests for technical help, determining proper request assignments, and assigning requests to available technicians. Other duties include answering the phone, reviewing and processing invoices, processing internal forms, and keeping electronic documentation. The position is responsible for all administrative duties for the IT Department including accounts payable, accounts receivable, cash deposits, monthly payroll, and ordering office and computer supplies. Work is performed independently with consultation and guidance on technical processes or applications. SPECIFIC DUTIES AND RESPONSIBILITIES ESSENTIAL JOB FUNCTIONS ADMINISTRATIVE- IT Department Handles accounting and budgetary functions for departments including monthly reports. Purchases operating supplies and materials in consultation with the supervisor. Provides recommendations on equipment and technology upgrades to the department head. Collects, reviews, sorts and distributes all incoming department mail. Reviews incoming invoices and bills, matching them to requisitions and purchase orders, and processing them for payment for departments. Scans and files all paid invoices, cash deposits, and purchase orders in electronic document software for later retrieval and review. Researches, develops and drafts a variety of materials including reports, memoranda, letters, and special accounting projects. Coordinates and handles a variety of records and management information such as logs, files and financial reports. Establishes records management systems or other indexing and retrieval systems for the department. Coordinates training and travel for staff. Prepares monthly payroll and maintains accrual accounts for the IT, GIS and E -911 Departments. Prepares cash deposits and transports deposits to Finance. Attends meetings and other events in the absence of the Department Head or supervisors. Assists the Department Head or supervisors with contacting service vendors; oversees office machine maintenance and supplies. Assist with budget material when needed. Technical Answers phone calls, directs calls, and greets customers in need of technical support. Provides accurate explanations of technician availability and processes technical requests. Assists customers with basic technical needs where applicable, such as password resets, simple application issues, etc. Updates and helps maintain technology request database. Runs reports and helps determine daily work flow of user group support technicians May attend IT related meetings and performs assigned duties in the absence of the IT Director. ADDITIONAL JOB FUNCTIONS Performs other related work as required. MINIMUM TRAINING AND EXPERIENCE An associate's degree in related field and at least one year experience or 4 years' experience in an office setting. Ability to manipulate data in Microsoft office products, especially Excel. SPECIAL REQUIREMENT Possession of a valid North Carolina driver's license PERFORMANCE INDICATORS Knowledge of Job: Has considerable knowledge of the policies and procedures of the IT Department's services. Has general knowledge of the organization and operation of County government. Is able to make administrative decisions in accordance with ordinances, laws, regulations and departmental procedures and policies. Is skilled in the operation of common office machines, including popular and specialized computer - driven word processing, spreadsheet and file maintenance programs. Is able to develop and modify work procedures, methods and processes to improve efficiency. Is able to communicate effectively orally and in writing. Is able to exercise tact and courtesy in frequent contact with a variety of public officials and the general public. Is able to establish and maintain effective working relationships as necessitated by work assignments. Quality of Work: Maintains high standards of accuracy in exercising duties and responsibilities. Exercises immediate remedial action to correct any quality deficiencies that occur in areas of responsibility. Maintains high quality communication and interacts within department and division, and with co- workers and the general public. Quantity of Work: Maintains effective and efficient output of all duties and responsibilities as described under "Specific Duties and Responsibilities." Dependability: Assumes responsibility for doing assigned work and meeting deadlines. Completes assigned work on or before deadlines in accordance with directives, County policy, standards and prescribed procedures. Accepts accountability for meeting assigned responsibilities in the technical, human and conceptual areas. Attendance: Attends work regularly and adheres to County policies and procedures regarding absences and tardiness. Provides adequate notice to higher management with respect to vacation time and time -off requests. Initiative and Enthusiasm: Maintains an enthusiastic, self - reliant and self - starting approach to meet job responsibilities and accountability. Strives to anticipate work to be done and initiates proper and acceptable direction for completion of work with a minimum of supervision and instruction. Judgment: Exercises analytical judgment in areas of responsibility. Identifies problems or situations as they occur and specifies decision objectives. Identifies or assist in identifying alternative solutions to problems or situations. Implements decisions in accordance with prescribed and effective policies and procedures and with a minimum of errors. Seeks expert or experienced advice and researches problems, situations and alternatives before exercising judgment. Cooperation: Accepts supervisory instruction and direction and strives to meet the goals and objectives of same. Questions such instruction and direction when clarification of results or consequences are justified, i.e., poor communications, variance with County policy or procedures, etc. Offers suggestions and recommendations to encourage and improve cooperation between all staff persons within the department. Relationships with Others: Shares knowledge with supervisors and staff for mutual and departmental benefit. Contributes to maintaining high morale among all department employees. Develops and maintains cooperative and courteous relationships with department employees, staffers and managers in other department, representatives from organizations, and the general public so as to maintain good will toward the department and project a good departmental image. Tactfully and effectively handles requests, suggestions and complaints from other departments and persons in order to maintain good will within the County. Interacts effectively with fellow employees, supervisor, professionals and the general public. Coordination of Work: Plans and organizes daily work routine. Establishes priorities for the completion of work in accordance with sound time - management methodology. Avoids duplication of effort. Estimates expected time of completion of elements of work and establishes a personal schedule accordingly. Attends meetings, planning sessions and discussions on time. Implements work activity in accordance with priorities and estimated schedules. Maintains a calendar for deadlines and events. Board Meeting Agenda Item MEETING DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Reclassification REQUESTED BY: John Roue, Jr., e' h Director REQUEST: At our last Board of Health meeting on November 19, 2015 the board approved for us to move forward with reclassifying a Public Health Nurse position to a Physician Extender II position. This reclassification will cause a small increase in the salary which we can absorb in our current budget. However this will be less expensive than contracting out for this service. We are seeking Board of Commissioner approval. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: U:1my documents\l- Winword\BOC Mtg Request\Phy Ext I1 request I- 2016.doc Page 1 of 1 FORM PD -I18 NORTH CAROLINA OFFICE OF STATE PERSONNEL INSTRUCTIONS FOR COMPLETING FORM PD.118 North Carolina Office of State Personnel 1. Submit original and (1) copy to OSP Consulting Team POSITION ACTION FORM 2. Sections 1,3,3,4, & 5 to be completed by IoM agency, Local Human Services Agencies: signed by County official (if required) & seed= 6 by Deportment of Social Services Office of State Personnel Public Health 3. Attach otiginal sad (1) copy of Position Deecdption Area Mental Health (PD10Z) to all requests except abolishment 4. Attach updated organizational chart 1. LOCAL AGENCY: HARNE'TT COUNTY HEALTH DEPARTMENT DATE SUBMITTED 12 -1415 UNIT /SECTION kclttlt 1 it:dth I. nit 2. BASIC POSITION INFORMATION: 'complete for all acaons nuguiated) Current Classification: Public Health Nurse II Type of position: \ Pe m : Ttsnpcaury 1'titt time T °a of time 3. POEMS ACTION WI lI :CK O\l?`: Regtu.•ated Efi cur a llitei 12.15,2015 .L — . :;rnFh Ncu. Position: Ciussi>uution , \hfrur cc! &J r• licidt. .lppxortal Salary Range $ J3 :tnllncatc- l'rapowd t'! tssificanoa Physician Extender I1 Position #ptmtltng . \ppctat t•d Sal try fir le_ra Ipprovcd Salazt Range 565,692 — 578.831— 5101,823 C-- .•\1v11i : 41_ I lxiving Posinon CI%Iwntication Position # 4. EXPLANATION: (Stan: needs for requested action. Identify special project positions.) . his po•lit,u is heing;cy,JC., it d fo.:.•tlarsificanon from PIN II potation to an Ph) skim Extender II position duc to change$ n clunt -01 :iced,. \pilm\ t.0 .x B( )i-1 and puiding 110L 3. AUTHORIZAT;ON BY LOCAL DEPARTMENT this request has been officitall% authorized end sufficient funds alt' l]Uj .'ll'G :11.1 :,puttee :ox ust. (2---)‘ -- V Vi/t.",....1✓ 12-14 -15 Agency Date County Official (if applicable) Date John Rouse..]:•.. 11;:v!th Director 6. 1pl�rca._ci CJar_ :.it :uiu L/5, C14r/ emder23r ccl season on IV% cm Action i•:t•.lurst ' Ld reason on na er:, OFHICEOF 'Aft PERSL;N :1 C,nuu uc "It t ci,e > tali ur .11tl;i ,), :0 rho r ti needed Pouticnl # 1^.rrt2ttivt• Date Date Approved f 1 / % �/ /' Re%tsed 1 2003 Board Meeting Agenda Item MEETING DATE: January 19, 2016 TO: HARNETT COUNTY BOARD OF COMMISSIONERS SUBJECT: Morgue MOU with • ; rnett a t REQUESTED BY: John Ro ealth Director REQUEST: The County is required by the General Statues to have a Morgue available for Medical Examiner Cases. I am seeking Board of Commissioner approval to enter into a Memorandum of Understanding with Harnett Health to provide these services at a cost of $50 per case. FINANCE OFFICER'S RECOMMENDATION: COUNTY MANAGER'S RECOMMENDATION: U:\my documents\1- Winword \BOC Mtg Request'Morgue request 1- 2016.doc Page 1 of 1 RECEIVED NOV 18 2015 BR'SCOUNTY OFFICE North Carolina Department of Health and Human Services Office of the Chief Medical Examiner Pat IvicC'ron Richard O. Brajer Secretary Governor Deborah L. Radisch, M.D.. M.P.H. Chief Medical Examiner County Managers. As you may already know. and pursuant to North Carolina Statute I -0A -381, each county shall provide or contract for an appropriate facility for the examination and storage of bodies under Medical Examiner.lurisdiction_ So that we can update our listing. please provide the designated bod: storage facility for your county b} emailing Lynn Poole at L,}nn.Pooie dhhs.nc.gor. Be sure to include: County Name Name of Facility Facility Address Facility Contact Name Facility Contact Title Facility Contact Phone Facility Contact Email Please provide this information no later than Friday, December 4, 2015. Also provided for your reference is a copy of a memorandum that was mailed out to Count) Managers in December 2011, by our Chief Medical Examiner, Dr. Deborah Radisch, further discussing legislation and appropriate storage. [Please ignore the last paragraph in the attached memo. as staffing changes have occurred] If you have questions, please feel free to reach out to me directl. Regards, Paula Rennie -Roed, URA Operations Manager, Office of the Chief Medical Examiner Epidemiology Section of the Division of Public Health NC Dept of Health and Human Services Physical Address: 4312 District Drive, Raleigh, NC' 27607.5491l Mailing Address: MSC 3025, Raleigh, NC 27699 -3025 Phone: 919 -743 -9074 Fax: 919 -743 -9099 Email: Paula .Hennie- Roed.a,dhhs.nc.t_ov OCHE Website: htty: 'w w .ocme.dhhs nc.gov www.ncdhhs.gov • www.ocme.dhhs.nc.go% Tel 919 -743 -9000 • Fax 919 -743 -9099 Location: 4312 District Drive • Raleigh, NC 27607 Mailing Address: 3025 Mail Service Center • Raleigh. NC 27699 -3025 . An Equal Opportunity Affirmative Action Emplo■er North Carolina Public Waldo ,g . North Carolina Department of Health and Human Services Division of Public Health Epidemiology Office of the Chief Medical Examiner Campus Box 7580 Chapel Hill, North Carolina 27599 -7580 Courier 17 -61 -02 Tel (919) 966 -2253 Fax (919) 962 -6263 Beverly Eaves Perdue, Governor Jeffrey P. Engel, MD, State Health Director Lanier M. Cansler, Secretary Deborah L. Radisch, MD, MPH. Chief Medical Examiner December 15, 2011 To: County Managers From: Deborah L. Radisch, MD, MPH Chief Medical Examiner Re: Body storage In 2007, an addition to the medical examiner (ME) statutes was made (see below, in bold): 130A381. Additional services and facilities. In order to provide proper facilities for investigating deaths as authorized in this Part, the Chief Medical Examiner may arrange for the use of existing public or private laboratory facilities. Each county shall provide or contract for an appropriate facility for the examination and storage of bodies under Medical Examiner jurisdiction. The Chief Medical Examiner may contract with qualified persons to perform or to provide support services for autopsies and other studies and investigations. (1967, c. 1154, s. 1; 1973, c. 476, s. 128; 1983, c. 891, s. 2; 2007187, s. 5.) The technical change to the statute was intended to clarify the role the county shares with the state in death investigation. Historically, under the coroner system that preceded the medical examiner system, the county provided a facility suitable for temporary storage of bodies. The county's responsibility for such a facility continued as the state transitioned to the medical examiner system. Each county through its governmental structure and local health department was and is expected to provide a facility where bodies can be stored pending a decision on death investigation, examination by the medical examiner, transportation to an autopsy facility, notification of next of kin, or arrangements for final disposition. The facility would be used for deaths under ME jurisdiction as well as natural deaths that do not fall under ME jurisdiction. Based on interactions with many different agencies over the past year, few counties are aware of this. The objective of this letter is to bring this legislation to your attention and urge your compliance with it. In many counties, hospitals have served as the place where ME bodies can be taken and held until they are examined by the ME and then released to the next of kin. ME rules permit hospitals to assess the state a fee of S40.00 when a county medical examiner orders a body taken to the hospital and later examines the body in that facility. Location: Brinkhous- Bultin Building UNC -CH Chapei Hitl,N.C. 27599 -7580 An Equal Opportunity / Affirmative Action Employer 10A NCAC 44.0204 Hospital Fee A fee of forty dollars ($40.00) is paid by the state to a hospital when a county medical examiner orders a body taken to the hospital and later examines the body in that facility. No payment is due a hospital when an autopsy is performed in that facility. No payment is due when the county medical examiner utilizes a hospital emergency room or other hospital facility for examination of a body transported to the hospital for examination. However, many counties do not have a hospital, or the hospital is not willing or able to provide this space. In these counties, a funeral home with a cooler might be an appropriate option, with the county contracting with the funeral home to compensate that establishment for the short -term use of their facility. In the rest of the counties, none of these may be an option and other arrangements must be made. In addition, there are many cases when a death clearly or most probably does not fall under ME jurisdiction; however, the next of kin is not immediately available to instruct where the body is to be transported. These cases cannot be covered under ME jurisdiction. In some of these counties, EMS and/or law enforcement is often detained at the scene of death, waiting for next of kin or the attending physician to be identified and contacted, wasting valuable county emergency resources. Even though this is not a ME system responsibility, l would encourage you to make similar facility and payment arrangements for these cases - -in other words, establish a county morgue for all deaths. I propose a deadline of June 1, 2012 for all counties to have this in place. Please contact Patricia Barnes at pat.bames @dhhs.nc.gov with your designated facility so that we can quickly and correctly provide the appropriate information to callers requesting it. 2016 Potential Harnett County Legislative Priorities Four Lane Highway from Harnett County into Wake County — Harnett County is the only county surrounding Wake County that does not have a four -lane highway into Wake County. This has been cited as a significant barrier to economic development in Harnett County. A four - lane highway into Wake County would have a significant positive economic impact on Harnett County. Authorize Counties to Operate Natural Gas as an Enterprise — Access to natural gas is a basic requirement for many industries and businesses looking for sites to locate new facilities. Despite a massive population influx in western Harnett County, a lack of natural gas has prevented the commercial and industrial growth that would normally accompany these increases in population. Harnett County asks for the same authorization municipalities have when it comes to expanding natural gas. Expand Broadband in Rural Harnett County Communities — Many portions of Harnett County do not currently have access to broadband. This is another significant barrier to economic growth in the county. Harnett County asks to be able to participate in developing infrastructure and providing broadband to underserved areas within the county. Authorize Use of Recreation Fees for Construction — Harnett County requests legislation that would grant the County the ability to use recreation fees, which are currently received from new development in the county, for construction as well as land acquisition. At present, counties can only use this revenue for land acquisition while municipalities are allowed to use them for both construction and land acquisition. Allow Harnett County to Establish a County -wide Tourism Entity — In last year's legislative session of the N.C. General Assembly, a bill was introduced that would have created a tax district for all of Harnett County outside of the Averasboro Township that would allow the Board of Commissioners to levy an occupancy tax of up to six percent for hotels, motels, inns, tourist camps and other similar lodgings, and to use these funds to establish a Harnett County Tourism Development Authority, which would use at least two thirds of these funds to promote travel and tourism with the rest going toward tourism - related expenditures in the district. This bill was not successful, however this issue may be a legislative priority for 2016. Allow Counties to use E -911 Funds for E -911 Needs Other than Equipment — Harnett County currently has E -911 funds which can only be used to purchase equipment, however the county has fulfilled all existing equipment needs. Harnett County asks for the flexibility to use leftover E -911 funds for personnel, training and other needs connected to the use of E -911. Choral Booster Club Harnett Central High School 2911 Harnett Central Road Angier, North Carolina 27501 January 7, 2016 Jim Burgin, Chairman Harnett County Board of Commissioners 102 E. Front Street Lillington, North Carolina 27546 Chairman Burgin and Harnett County Commissioners, The Vocal Ensemble has been invited to sing at Carnegie Hall in New York City and the expense exceeds $70,000.00. To date, we have raised approximately $50,000.00 and have approximately $20,000.00 - $25,000.00 more to raise. The Harnett Central High School Choral Booster Club requests a donation or match of funds from the Harnett County Board of Commissioners for the Vocal Ensemble's April 2016 trip to New York City. Each student is responsible for $1,300 to pay their way on the trip. The parents were given a payment schedule at the beginning of the school year which they have been adding to the students "accounts ". Students have been given fundraising opportunities to earn funds to go towards their $1,300.00 portion. Approximately $32,000.00 has been funded by the parents and /or students. Fundraising outlets completed so far include: Butter Braid, Yankee Candle, and World's Finest Chocolate sales, a pancake breakfast at Applebee's, and sponsorship letters mailed out to private and corporate sponsors in Harnett County. We have received approximately $12,000 through our sponsorship letter campaign. Other fundraising opportunities we have planned for 2016: a Chili Cook -off, a BBQ Chicken Cookout, and a benefit concert on March 24th at Campbell University. The Vocal Ensemble recently won the WRAL.FM Christmas Choir Competition and secured a $5,000.00 grand prize. We have had one match on the WRAL.FM Christmas Choir Competition. The Choral Booster Club requests a donation or a match of funds from the Harnett County Board of Commissioners to assist the Harnett Central High School Vocal Ensemble with this once in a lifetime opportunity to sing at Carnegie Hall in New York City in April. Thank you for your consideration, Choral Booster Club Members and the students of the Harnett Central High School Vocal Ensemble Cc: Devin Hocutt, HCHS Music Teacher 2015 Boards and Committees on which Commissioners Serve Commissioner Jim Burgin CCCC Board of Trustees Home & Community Care Block Grant Committee Mid - Carolina Council of Governments Board of Directors Mid - Carolina Aging Advisory Committee Industrial Facilities /Pollution Control Financing Authority Commissioner C. Gordon Springle Social Services Board BRAC Regional Task Force Capital Area Metropolitan Planning Organization (CAMPO) Employee Benefits Committee Johnston- Lee - Harnett Community Action Board of Directors Rural Planning Organization for Transportation (TAC) Southeastern Economic Development Commission Transportation Advisory Committee (FAMPO) Transportation Advisory Board Commissioner Abe Elmore Airport Committee Averasboro Township Tourism Development Authority Central Carolina Works Advisory Committee (3/2/15) Commissioner Barbara McKoy Board of Health Juvenile Crime Prevention Council Library Board Sandhills Center for Mental Health DDSHS Commissioner Joe Miller Architectural Committee (Schools) Cape Fear River Assembly Board CCCC Harnett County Campus Advisory Comm. Extension Advisory Leadership Council Good Hope Board