PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ATMORE AMBULANCE, INC / LIC # 966

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 06, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Please correct all mechanical and equipment non compliance within 10 days.

Front office needs to be secured from public access while patient reports are out.

Med Control Hospital: SPRING HILL MEMORIAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ATMORE AMBULANCE, INC / LIC # 966

VEHICLE INSPECTION SUMMARY:

Vehicle M1: Passed with DeficienciesEmergency Lights, Load Lights, Head/Taillights, Patient Rain Cover (2)Emergency lights out on driver side and passenger side front fendersCenter amber colored light out on rearRight front headlight outRight rear tire outside tire worn

Vehicle M2: Mechanical

Vehicle M3: Passed with DeficienciesHemostatic Agents (2), Pulse Oximetry (1)/Pediatric1 Atropine expired

Vehicle M5: Mechanical

Vehicle M6: Passed with DeficienciesWindshield, MirrorsWindshield needs to be replaced ASAP

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - CHILTON / LIC # 1004

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 13, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 120: Mechanical

Vehicle 130: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, Zofran (equivalent to OndansetronExpired ET TubesZofran expired

Vehicle 105: Passed with DeficienciesLoad Lights, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, ET Tubes 6.0mm-9.0mm (cuffed)(3)/AdultLoad light out on rearExpired ET Tubes

Vehicle 167: Mechanical

Vehicle 170: Passed

Vehicle 139: Not Inspected

Unit on a call

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 13, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - DALLAS / LIC # 872

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Vehicles that are marked "Not Inspected" were not currently under the management of this location.

136 Insepected-Right rear turn signal-Emergency lights in front grill-Passed with deficiencies

143 Inspected-Passed

78 Inspected (BLS)-Passed

107 Inspected-Passed

Med Control Hospital: VAUGHN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - DALLAS / LIC # 872

VEHICLE INSPECTION SUMMARY:

Vehicle 118: Passed

Vehicle 103: Not Inspected

Vehicle 111: Not Inspected

Vehicle 72: Not Inspected

Vehicle 76: FailedHeat/AC F/R

Vehicle 115: Not Inspected

Vehicle 122: Not Inspected

Vehicle 141: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - LOWNDES / LIC # 752

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Med Control Hospital: VAUGHN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 88: Passed

Vehicle 133: Passed

Vehicle 125: Not Inspected

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - MACON / LIC # 857

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web mangement needs to be updated

Unit 144 Inspected - Passed with DeficienciesExpired ET Tubes

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 140: Not Inspected

Expired ET Tube

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - PERRY / LIC # 958

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 88: Passed

Vehicle 133: Passed

Vehicle 134: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - RUSSELL / LIC # 856

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 14, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated.

Unit 122 inspected - Passed

Unit 106 inspected - Passed

Unit 135 inspected - Passed

Unit 137 inspected - Passed

Unit 92 inspected - Passed

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 14, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - RUSSELL / LIC # 856

VEHICLE INSPECTION SUMMARY:

Vehicle 60: Not Inspected

Vehicle 204: Not Inspected

Vehicle 169: Not Inspected

Vehicle 102: Not Inspected

Vehicle 163: Passed

Vehicle 168: Not Inspected

Vehicle MED 2: Passed

Vehicle 142: Passed

Vehicle 71: Not Inspected

Vehicle 116: Passed

Vehicle 117: Passed with DeficienciesPulse Oximetry (1)/Pediatric

Vehicle 131: Passed with DeficienciesPulse Oximetry (1)/Pediatric

Vehicle 132: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/PediatricETTube expired

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 14, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CHILDERSBURG AMBULANCE SERVICE / LIC # 159

Veh Inspect Only?: NOwner Type: City - EMSPassed with Deficiencies

June 22, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 1474: Passed

Vehicle 1473: FailedTires, Heat/AC F/RLeft front tire showing extensive wear patterns on inside portion with possible seperation signs.Front and rear A/C blowing hot air only

Vehicle 1472: Passed with DeficienciesLoad LightsScene light outEmergency light on grill out

Vehicle 1471: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 22, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CLANTON FIRE DEPARTMENT / LIC # 484

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

July 13, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R 22: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Vehicle E 3: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Vehicle R 21: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 13, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CONECUH COUNTY EMS / LIC # 570

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 07, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated.

Unit 480 Inspected - Passed with DeficienciesET Tubes expiredPediatric Laryngoscope handle not functionalBougies expiredNo pediatric Pulse Ox14ga IV catheters expired

Med Control Hospital: EVERGREE MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 482: Mechanical

Vehicle 481: Mechanical

Vehicle 483: Not Inspected

Unit on a call

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 07, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

D.W. MCMILLAN EMS / LIC # 197

Veh Inspect Only?: NOwner Type: County - EMSPassed

July 07, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: D W MCMILLIAN MEMORIAL

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle EM2: Passed

Vehicle EM 3: Passed

Vehicle EM1: Passed

Vehicle EM-4: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 07, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ESCAMBIA COUNTY EMS / LIC # 221

Veh Inspect Only?: NOwner Type: CountyPassed

July 06, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated

Unit 10 Inspected - Passed with DeficienciesNo Haloperidol

Med Control Hospital: MONROE COUNTY HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 13: Passed with DeficienciesHaloperidol250mL Normal Saline Expired

Vehicle 19: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE- MACON / LIC # 1084

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: JACKSON HOSPITAL MONTGOMERY

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle M41: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE, INC. - MONTGOMERY / LIC # 1058

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: FLOWERS HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE, INC. - MONTGOMERY / LIC # 1058

VEHICLE INSPECTION SUMMARY:

Vehicle M17: Mechanical

Vehicle M31: Passed

Vehicle M27: Mechanical

Vehicle M18: Passed with Deficiencies

Vehicle M41: Passed

Vehicle M40: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/InfantExpired ET Tubes

Vehicle M38: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/InfantET Tubes expired

Vehicle M44: Passed

Vehicle M30: Mechanical

Vehicle M32: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/PediatricET Tubes expired

Vehicle M29: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

GOODWATER AMBULANCE SERVICE / LIC # 246

Veh Inspect Only?: NOwner Type: City - FirePassed

June 23, 2016Jamie Gray

ALS/BLS: BLSOutcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 002: Passed

Vehicle 001: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 23, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HAYNES AMBULANCE OF TROY, LLC / LIC # 982

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 24, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: TROY REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HAYNES AMBULANCE OF TROY, LLC / LIC # 982

VEHICLE INSPECTION SUMMARY:

Vehicle 404: Passed

Vehicle 408: Passed

Vehicle 403: Not Inspected

Vehicle SR4: Passed

Vehicle 423: Passed

Vehicle 446: Passed

Vehicle 443: Not Inspected

Vehicle 444: Mechanical

Needs winshield replaced

Vehicle 407: Passed

Vehicle 420: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

INTERNATIONAL PAPER / LIC # 402

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed with Deficiencies

July 08, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: PRATTVILLE BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle MEDIC 1: Passed with DeficienciesAtropine Sulfate, HaloperidolValium on recall - paperwork in hand

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 08, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

JEMISON FIRE & RESCUE / LIC # 282

Veh Inspect Only?: NOwner Type: City - FirePassed

July 01, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Update tag for R 40 in web management

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R 41: Not Inspected

Down for mechanical issues

Vehicle R 40: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 01, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

KELLYTON FIRE & RESCUE / LIC # 919

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed

June 23, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: RUSSELL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle MEDIC 1: Not Inspected

Vehicle MEDIC 3: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 23, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

PRATTVILLE FIRE DEPARTMENT / LIC # 348

Veh Inspect Only?: NOwner Type: City - FirePassed

June 16, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: PRATTVILLE BAPTIST HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 16, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

PRATTVILLE FIRE DEPARTMENT / LIC # 348

VEHICLE INSPECTION SUMMARY:

Vehicle E2: Passed

Vehicle E3: Passed

Vehicle E-4: Passed

Vehicle 09-106: Passed

Vehicle R-1: Not Inspected

Vehicle 09-107: Passed

Vehicle 09-105: Passed

Vehicle R1: Passed

Vehicle 09-104: Passed

Vehicle 09-102: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 16, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SYLACAUGA AMBULANCE SERVICE / LIC # 389

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 22, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

3175-InspectedPassed

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle SA 8: Not Inspected

Truck mechanically out of service until futher notice. Blown engine.

Vehicle SA 2: Not Inspected

Vehicle 3173: Not Inspected

Vehicle mechanically out of service. Transmission shop

Vehicle SA 7: Passed

Vehicle SA 1: Passed

Vehicle 3174: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 22, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

THORSBY FIRE DEPARTMENT / LIC # 395

Veh Inspect Only?: NOwner Type: City - FirePassed

June 30, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle ENG-32: Passed

Vehicle ENG-31: Passed

Vehicle RES-3: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 30, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

TROY FIRE DEPARTMENT / LIC # 1017

Veh Inspect Only?: NOwner Type: County - FirePassed

June 24, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: TROY REGIONAL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 01: Passed

Vehicle 02: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ALABASTER FIRE DEPARTMENT / LIC # 107

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 31, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate Yes

DRUG SUMMARY:

Sanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

No Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E 12: Passed with DeficienciesChest Needle Decompression Kit (1)

Vehicle E 13: Passed with DeficienciesNasal Cannulae with Tubing (3)/Adult

Vehicle E 11: Passed with DeficienciesBougie Device (1)/Adult

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

09/01/2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

A-MED AMBULANCE SERVICE - ETOWAH / LIC # 965

Veh Inspect Only?: NOwner Type: City - EMSPassed with Deficiencies

November 01, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Need to update Web ManagementA54- Missing No Smoking Signs, expired ET Tubes - Passed with DeficienciesA17- Expired BIAD-Passed with Deficiencies

Med Control Hospital: GADSDEN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

November 02, 2016 1/3

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

A-MED AMBULANCE SERVICE - ETOWAH / LIC # 965

VEHICLE INSPECTION SUMMARY:

Vehicle A42: Passed with DeficienciesNo Smoking Signs F/R

Vehicle A81: Passed with DeficienciesNo Smoking Signs F/R

Vehicle A16: Passed with DeficienciesNo Smoking Signs F/R

Vehicle A32: Passed with DeficienciesIV Pressure Infuser (1), Epinephrine (equivalent to Adrenalin) 1: 10,000 and 1:1,000

Vehicle A50: Mechanical

Vehicle A80: Passed with DeficienciesPortable Suction (Battery Operated) (1), 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A31: Verify Roster

Vehicle A10: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A 51: Mechanical

Vehicle A61: Passed with DeficienciesN.P.A. (12-34 fr) (6 Assorted)/A/P/I, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each), Sodium Bicarbonate

Vehicle A52: Passed with DeficienciesNo Smoking Signs F/R, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A71: Passed with DeficienciesNo Smoking Signs F/R, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A53: Passed

Vehicle A62: Passed with DeficienciesSeated Immobilization Device (1), Pulse Oximetry (1)/Pediatric, BIAD (1)/Adult, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A40: Passed with DeficienciesNo Smoking Signs F/R, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A11: Passed with DeficienciesBIAD (1)/Adult, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

November 02, 2016 2/3

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

A-MED AMBULANCE SERVICE - ETOWAH / LIC # 965

Vehicle A43: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle A15: Passed with DeficienciesStethoscope (1)/Pediatric, ET Placement Detector (2), Cardiac Monitor/Defibrillator with ECG Print Out and Spare Battery (1), 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A14: Passed with Deficiencies3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A33: Passed with DeficienciesNo Smoking Signs F/R, OB Kit (1)

Vehicle A 70: Passed with Deficiencies3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A63: Passed with DeficienciesMagill Forceps (1)/Adult, 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Vehicle A3: Mechanical

Vehicle A 20: Verify Roster

Vehicle A12: Passed

Vehicle A30: Passed with DeficienciesLoad Lights, No Smoking Signs F/R

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

November 02, 2016 3/3

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

AM SERV EMS - BIBB / LIC # 112

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed with Deficiencies

November 03, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: DCH REGIONAL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle AS#12: Passed with DeficienciesLoad Lights, Windshield, Pulse Oximetry (1)/Pediatric, Magill Forceps (1)/Pediatric, Automatic External Defibrillator (AED) Device (1)/Adult

Vehicle AS#14: Passed

Vehicle AS#15: FailedWindshield

Vehicle AS#16: Passed with DeficienciesLoad Lights

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

November 03, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ARJENNA PARABASIC TRANSPORT LLC / LIC # 953

Veh Inspect Only?: YOwner Type: For Profit - EMSPassed

August 16, 2016Beverly Edwards

ALS/BLS: BLSOutcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: SHELBY BAPTIST

VEHICLE INSPECTION SUMMARY:

Vehicle T-104: Passed

Vehicle 102: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 16, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ATMORE AMBULANCE, INC / LIC # 966

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 06, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Please correct all mechanical and equipment non compliance within 10 days.

Front office needs to be secured from public access while patient reports are out.

Med Control Hospital: SPRING HILL MEMORIAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ATMORE AMBULANCE, INC / LIC # 966

VEHICLE INSPECTION SUMMARY:

Vehicle M1: Passed with DeficienciesEmergency Lights, Load Lights, Head/Taillights, Patient Rain Cover (2)Emergency lights out on driver side and passenger side front fendersCenter amber colored light out on rearRight front headlight outRight rear tire outside tire worn

Vehicle M2: Mechanical

Vehicle M3: Passed with DeficienciesHemostatic Agents (2), Pulse Oximetry (1)/Pediatric1 Atropine expired

Vehicle M5: Mechanical

Vehicle M6: Passed with DeficienciesWindshield, MirrorsWindshield needs to be replaced ASAP

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

BESSEMER FIRE DEPARTMENT / LIC # 131

Veh Inspect Only?: NOwner Type: City - Fire

October 20, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: UAB MEDICAL WEST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle ENG-4: Passed

Vehicle ENG-3: Passed

Vehicle ENG-1: Passed

Vehicle ENG-2: Passed

Vehicle ENG-5: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 20, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CAHABA VALLEY FIRE - SHELBY / LIC # 145

Veh Inspect Only?: NOwner Type: County - EMSPassed

October 12, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: GRANDVIEW MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E-181: Passed

Vehicle R-183: Passed

Vehicle R-181: Passed

Vehicle E-183: Passed

Vehicle R-185: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 12, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CALERA FIRE DEPARTMENT / LIC # 146

Veh Inspect Only?: NOwner Type: City - FirePassed

October 21, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle Q 22: Passed

Vehicle BAT 20: Passed

Vehicle E21: Passed

Vehicle E23: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 21, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - CHILTON / LIC # 1004

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 13, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 120: Mechanical

Vehicle 130: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, Zofran (equivalent to OndansetronExpired ET TubesZofran expired

Vehicle 105: Passed with DeficienciesLoad Lights, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, ET Tubes 6.0mm-9.0mm (cuffed)(3)/AdultLoad light out on rearExpired ET Tubes

Vehicle 167: Mechanical

Vehicle 170: Passed

Vehicle 139: Not Inspected

Unit on a call

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 13, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - DALLAS / LIC # 872

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Vehicles that are marked "Not Inspected" were not currently under the management of this location.

136 Insepected-Right rear turn signal-Emergency lights in front grill-Passed with deficiencies

143 Inspected-Passed

78 Inspected (BLS)-Passed

107 Inspected-Passed

Med Control Hospital: VAUGHN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - DALLAS / LIC # 872

VEHICLE INSPECTION SUMMARY:

Vehicle 118: Passed

Vehicle 103: Not Inspected

Vehicle 111: Not Inspected

Vehicle 72: Not Inspected

Vehicle 76: FailedHeat/AC F/R

Vehicle 115: Not Inspected

Vehicle 122: Not Inspected

Vehicle 141: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - LOWNDES / LIC # 752

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Med Control Hospital: VAUGHN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 88: Passed

Vehicle 133: Passed

Vehicle 125: Not Inspected

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - MACON / LIC # 857

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web mangement needs to be updated

Unit 144 Inspected - Passed with DeficienciesExpired ET Tubes

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 140: Not Inspected

Expired ET Tube

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - PERRY / LIC # 958

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 17, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be updated ASAP

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 88: Passed

Vehicle 133: Passed

Vehicle 134: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 20, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - RUSSELL / LIC # 856

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 14, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated.

Unit 122 inspected - Passed

Unit 106 inspected - Passed

Unit 135 inspected - Passed

Unit 137 inspected - Passed

Unit 92 inspected - Passed

Med Control Hospital: VAUGHAN REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 14, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CARE AMBULANCE - RUSSELL / LIC # 856

VEHICLE INSPECTION SUMMARY:

Vehicle 60: Not Inspected

Vehicle 204: Not Inspected

Vehicle 169: Not Inspected

Vehicle 102: Not Inspected

Vehicle 163: Passed

Vehicle 168: Not Inspected

Vehicle MED 2: Passed

Vehicle 142: Passed

Vehicle 71: Not Inspected

Vehicle 116: Passed

Vehicle 117: Passed with DeficienciesPulse Oximetry (1)/Pediatric

Vehicle 131: Passed with DeficienciesPulse Oximetry (1)/Pediatric

Vehicle 132: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/PediatricETTube expired

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 14, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CHELSEA FIRE & RESCUE / LIC # 154

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 30, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate Yes

DRUG SUMMARY:

Sanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R-31: Passed with DeficienciesNo Smoking Signs F/R, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult, Bougie Device (1)/Adult, Diazepam (equivalent to Valium) or Lorazepam or both, Lidocaine HCL (equivalent to Xylocaine) Premix

Vehicle R-38: Mechanical

Vehicle E-32: Passed with DeficienciesNo Smoking Signs F/R, Bag-Valve Mask (BVM) (2)/Adult, Bag-Valve Mask (BVM) (2)/Infant

Vehicle E-31: Passed with DeficienciesBag-Valve Mask (BVM) (2)/Adult, Bag-Valve Mask (BVM) (2)/Pediatric, Naloxone (equivalent Narcan)

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

09/01/2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CHELSEA FIRE & RESCUE / LIC # 154

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

October 12, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Waiting on Web Management to update.R-31 will be renumbered to R39R-31 2016 Dodge -Passed

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R-31: Not Inspected

Vehicle R-38: Passed with DeficienciesWindshield, Chest Seal (1), ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle E-32: Not Inspected

Vehicle E-31: Not Inspected

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 13, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CHILDERSBURG AMBULANCE SERVICE / LIC # 159

Veh Inspect Only?: NOwner Type: City - EMSPassed with Deficiencies

June 22, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 1474: Passed

Vehicle 1473: FailedTires, Heat/AC F/RLeft front tire showing extensive wear patterns on inside portion with possible seperation signs.Front and rear A/C blowing hot air only

Vehicle 1472: Passed with DeficienciesLoad LightsScene light outEmergency light on grill out

Vehicle 1471: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 22, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CLANTON FIRE DEPARTMENT / LIC # 484

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

July 13, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R 22: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Vehicle E 3: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Vehicle R 21: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Intraosseous (IO) Infusion Needles (1)/Adult, Intraosseous (IO) Infusion Needles (1)/Pediatric

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 13, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

CONECUH COUNTY EMS / LIC # 570

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

July 07, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated.

Unit 480 Inspected - Passed with DeficienciesET Tubes expiredPediatric Laryngoscope handle not functionalBougies expiredNo pediatric Pulse Ox14ga IV catheters expired

Med Control Hospital: EVERGREE MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 482: Mechanical

Vehicle 481: Mechanical

Vehicle 483: Not Inspected

Unit on a call

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 07, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

D.W. MCMILLAN EMS / LIC # 197

Veh Inspect Only?: NOwner Type: County - EMSPassed

July 07, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: D W MCMILLIAN MEMORIAL

Drug Area Locked: Space Allocation: Outdated Storage:Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle EM2: Passed

Vehicle EM 3: Passed

Vehicle EM1: Passed

Vehicle EM-4: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 07, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

ESCAMBIA COUNTY EMS / LIC # 221

Veh Inspect Only?: NOwner Type: CountyPassed

July 06, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated

Unit 10 Inspected - Passed with DeficienciesNo Haloperidol

Med Control Hospital: MONROE COUNTY HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 13: Passed with DeficienciesHaloperidol250mL Normal Saline Expired

Vehicle 19: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 06, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE- MACON / LIC # 1084

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: JACKSON HOSPITAL MONTGOMERY

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle M41: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE, INC. - MONTGOMERY / LIC # 1058

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

June 29, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: FLOWERS HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

EXCELSIOR AMBULANCE SERVICE, INC. - MONTGOMERY / LIC # 1058

VEHICLE INSPECTION SUMMARY:

Vehicle M17: Mechanical

Vehicle M31: Passed

Vehicle M27: Mechanical

Vehicle M18: Passed with Deficiencies

Vehicle M41: Passed

Vehicle M40: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/InfantExpired ET Tubes

Vehicle M38: Passed with DeficienciesET Tubes 2.0mm-3.5mm (uncuffed) (3)/InfantET Tubes expired

Vehicle M44: Passed

Vehicle M30: Mechanical

Vehicle M32: Passed with DeficienciesET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/PediatricET Tubes expired

Vehicle M29: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 29, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

GOODWATER AMBULANCE SERVICE / LIC # 246

Veh Inspect Only?: NOwner Type: City - FirePassed

June 23, 2016Jamie Gray

ALS/BLS: BLSOutcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 002: Passed

Vehicle 001: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 23, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

GREEN POND F & R / WEST ALABAMA EMERGENCY SERVICE / LIC # 748

Veh Inspect Only?: NOwner Type: Non-Profit - FirePassed with Deficiencies

November 04, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: DCH TUSCALOOSA

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R-200: Verify Roster

Vehicle R 10: Passed with DeficienciesObstetric Kit (1), N.P.A. (12-34 fr) (6 Assorted)/A/P/I, IV Catheters (14, 16, 18, 20, 22, and 24 gauge) (3 each)/A/P/I, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, Magnesium Sulfate

Vehicle R-100: Verify Roster

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

November 04, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HARPERSVILLE FIRE DEPARTMENT / LIC # 861

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 30, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate Yes

DRUG SUMMARY:

Sanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 302: Passed with DeficienciesPulse Oximetry (1)/Pediatric

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

09/01/2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HAYNES AMBULANCE OF TROY, LLC / LIC # 982

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 24, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: TROY REGIONAL HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HAYNES AMBULANCE OF TROY, LLC / LIC # 982

VEHICLE INSPECTION SUMMARY:

Vehicle 404: Passed

Vehicle 408: Passed

Vehicle 403: Not Inspected

Vehicle SR4: Passed

Vehicle 423: Passed

Vehicle 446: Passed

Vehicle 443: Not Inspected

Vehicle 444: Mechanical

Needs winshield replaced

Vehicle 407: Passed

Vehicle 420: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HELENA FIRE DEPARTMENT / LIC # 271

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 16, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle ENG-61: Passed with DeficienciesBIAD (1)/Adult

Vehicle ENG-62: Passed with DeficienciesEmergency Lights, Non-Rebreathing Mask with Tubing (1)/Infant, Nasal Cannulae with Tubing (1)/Infant

Vehicle ENG-63: Passed

Vehicle TRUCK 62: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 16, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

H E M S I / LIC # 254

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed

October 25, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Waiting on Web Management to update the following changes: 2002 is now 2102, 2001 is now 2101, 1003 is now 1103, need to add 1165, need to add 2103 (vin# 34827), need to add 1101. 1165- Passed2103- Passed1101- Passed

Med Control Hospital: HUNTSVILLE HOSPITAL / CRESTWOOD MEDICAL CENTER / MADISON HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 27, 2016 1/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

H E M S I / LIC # 254

VEHICLE INSPECTION SUMMARY:

Vehicle 2001: Passed

Vehicle 2002: Passed

Vehicle 1004: Passed

Vehicle 1147: Passed

Vehicle 1014: Passed

Vehicle 1009: Passed

Vehicle 1159: Passed

Vehicle 1157: Mechanical

Vehicle 1161: Mechanical

Vehicle 1002: Passed

Vehicle 1143: Passed

Vehicle 1010: Passed

Vehicle 1164: Passed

Vehicle 1016: Passed

Vehicle 1141: Passed

Vehicle 1102: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 27, 2016 2/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

H E M S I / LIC # 254

Vehicle 1003: Passed

Vehicle 31: Mechanical

Vehicle 50: Passed

Vehicle 1006: Mechanical

Vehicle 1005: Passed

Vehicle CCT-2: Passed

Vehicle KC-1: Passed

Vehicle 1258: Passed

Vehicle 1115: Passed

Vehicle 1019: Passed

Vehicle 1018: Passed

Vehicle 1008: Passed

Vehicle 1011: Passed

Vehicle 1249: Passed

Vehicle 1240: Passed

Vehicle 1012: Passed

Vehicle 1017: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 27, 2016 3/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

H E M S I / LIC # 254

Vehicle 1163: Mechanical

Vehicle 1162: Mechanical

Vehicle CCT-3: Passed

Vehicle 1007: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 27, 2016 4/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HOOVER FIRE DEPARTMENT - SHELBY / LIC # 593

Veh Inspect Only?: NOwner Type: City - Fire

October 14, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

E-8 Missing signatures on Morphine Log.R-42 Missing signatures on Morphine Log.

Med Control Hospital: UAB

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes No YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E-3: Passed with DeficienciesIV Catheters (14, 16, 18, 20, 22, and 24 gauge) (5 each), ET Placement Detector (2)

Vehicle Q-7: Passed with DeficienciesNasal Cannulae with Tubing (3)/Infant, Suction Catheter (Tonsil Tip) (2)/Adult, Magill Forceps (1)/Pediatric

Vehicle E-8: Passed with DeficienciesSuction Catheter (Tonsil Tip) (2)/Adult

Vehicle E-9: Passed with DeficienciesNon-Rebreathing Mask with Tubing (3)/Pediatric, Nasal Cannulae with Tubing (3)/Infant, Magill Forceps (1)/Pediatric, BIAD (1)/Adult, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle R-42: Passed with DeficienciesNo Smoking Signs F/R

Vehicle R-45: Passed with DeficienciesSeat Belts F/R, No Smoking Signs F/R, Hemostatic Agents (2), Pedi Wheel or Tape (1), CO2 Monitoring Equipment (2)/Pediatric, Cardiac Monitor/Defibrillator with ECG Print Out and Spare Battery (1), Chest Needle Decompression Kit (1), 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 14, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

HOOVER FIRE DEPARTMENT - SHELBY / LIC # 593

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 14, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

INTERNATIONAL PAPER / LIC # 402

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed with Deficiencies

July 08, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: PRATTVILLE BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle MEDIC 1: Passed with DeficienciesAtropine Sulfate, HaloperidolValium on recall - paperwork in hand

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 08, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

IRONDALE FIRE DEPARTMENT / LIC # 280

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

November 23, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate Yes

DRUG SUMMARY:

Sanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E 3: Passed with DeficienciesIV Catheters (14, 16, 18, 20, 22, and 24 gauge) (3 each)/A/P/I

Vehicle E 2: Passed with DeficienciesBag-Valve Mask (BVM) (1)/Pediatric, Bag-Valve Mask (BVM) (1)/Infant, ET Placement Detector (1)

Vehicle E 1: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

11/28/2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

JEMISON FIRE & RESCUE / LIC # 282

Veh Inspect Only?: NOwner Type: City - FirePassed

July 01, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Update tag for R 40 in web management

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R 41: Not Inspected

Down for mechanical issues

Vehicle R 40: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

July 01, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

KELLYTON FIRE & RESCUE / LIC # 919

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed

June 23, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: RUSSELL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle MEDIC 1: Not Inspected

Vehicle MEDIC 3: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 23, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

LIFECARE OF ALABAMA - JEFFERSON / LIC # 821

Veh Inspect Only?: NOwner Type: For Profit - EMS

August 26, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Need to update the Web Management.

Need updated Protocol books on ambulances.

MT 16 load light out, expired ET tubes, need pediatric pulse ox, passed with deficiencies.

Med Control Hospital: TDCH

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 26, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

LIFECARE OF ALABAMA - JEFFERSON / LIC # 821

VEHICLE INSPECTION SUMMARY:

Vehicle MT 4: Verify Roster

Vehicle MT 11: Verify Roster

Vehicle MT 14: Passed with DeficienciesLoad Lights, No Smoking Signs F/R, Pulse Oximetry (1)/Pediatric

Vehicle MT 15: Verify Roster

Vehicle MT 13: Passed with DeficienciesPulse Oximetry (1)/Pediatric, Thiamine

Vehicle MT 12: Verify Roster

Management states ambulance unit was inspected in Tuscaloosa.

Vehicle 5: Verify Roster

Vehicle MT6: Verify Roster

Vehicle 3: Verify Roster

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 26, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

MCADORY FIRE DEPARTMENT / LIC # 501

Veh Inspect Only?: NOwner Type: County - Fire

October 19, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: U A B MEDICAL WEST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 611: Passed

Vehicle 601: Passed

Vehicle 602: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 19, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

MONTEVALLO FIRE & RESCUE SERVICE / LIC # 312

Veh Inspect Only?: NOwner Type: City - EMSPassed

October 28, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate NoSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle R-21: Passed

Vehicle R-20: Passed

Vehicle E-83: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 28, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

NORTH SHELBY FIRE DEPARTMENT / LIC # 328

Veh Inspect Only?: NOwner Type: County - FirePassed with Deficiencies

October 05, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E 71: Passed with DeficienciesNon-Rebreathing Mask with Tubing (3)/Adult, Non-Rebreathing Mask with Tubing (3)/Pediatric, Non-Rebreathing Mask with Tubing (3)/Infant, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult

Vehicle E 72: Passed with DeficienciesBIAD (1)/Adult

Vehicle R-73: Passed with DeficienciesIntraosseous (IO) Infusion Needles (1)/Pediatric, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult

Vehicle R 72: Passed with DeficienciesHemostatic Agents (2), Wave Form Capnography (required by June 2013) (1), ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 05, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

NORTHSTAR PARAMEDIC SERVICES - TUSCALOOSA / LIC # 330

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

August 23, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Web management needs to be updated.

Unit 114 Grounded due to A/C.

Unit 127 inspected missing BLS drugs. Passed with deficiencies.

Med Control Hospital: DCH REGIONAL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 23, 2016 1/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

NORTHSTAR PARAMEDIC SERVICES - TUSCALOOSA / LIC # 330

VEHICLE INSPECTION SUMMARY:

Vehicle 98: Verify Roster

Vehicle 107: Verify Roster

Vehicle 115: Passed with DeficienciesHemostatic Agents (2)

Vehicle 116: Passed with DeficienciesNo Smoking Signs F/R, Hemostatic Agents (2), Chest Seal (1), Magill Forceps (1)/Pediatric, Oral Glucose Paste (1), Aspirin (1 bottle), Arterial Tourniquet (1)/Adult, Current Protocol Book, Triangular Reflectors or Equivalent (3)

Vehicle 118: Passed

Vehicle 120: Passed with Deficiencies

Vehicle 125: Mechanical

Vehicle 113: Passed

Vehicle 122: Passed with DeficienciesLoad Lights, Windshield, Patient Restraints (1 set), Hemostatic Agents (2), Chest Seal (1), Bandage Shears (1), Blood Pressure Cuff (1)/Pediatric, Pulse Oximetry (1)/Pediatric, Magill Forceps (1)/Pediatric, Oral Glucose Paste (1), Aspirin (1 bottle), Digital Blood Glucose Meter (1)

Vehicle 123: Passed with DeficienciesEmergency Lights, Load Lights, No Smoking Signs F/R, Hemostatic Agents (2), ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle 106: Verify Roster

Vehicle 121: Passed with DeficienciesLaryngoscope Handle (1), ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, ET Tubes 6.0mm-9.0mm (cuffed) (3)/AdultExpired ET Tubes

Vehicle 124: Passed with DeficienciesHemostatic Agents (2)

Vehicle 126: Passed with DeficienciesNo Smoking Signs F/R, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult

Vehicle 65: Verify Roster

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 23, 2016 2/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

NORTHSTAR PARAMEDIC SERVICES - TUSCALOOSA / LIC # 330

Vehicle 86: Verify Roster

Vehicle 65: Verify Roster

Vehicle 109: Verify Roster

Vehicle 110: Verify Roster

Vehicle 111: Passed with DeficienciesHemostatic Agents (2), Oral Glucose Paste (1), Aspirin (1 bottle), Aspirin, Glucose, Oral paste (equivalent to Instant Glucose)*, Naloxone (equivalent Narcan)No MAD

Vehicle 112: Verify Roster

Vehicle 119: Verify Roster

Vehicle 133: Mechanical

Vehicle 134: Passed with DeficienciesNo Smoking Signs F/R

Vehicle 136: Passed

Vehicle 145: Mechanical

Vehicle 105: FailedWindshield, Multi-trauma Dressings (2), Hemostatic Agents (2), Chest Seal (1), Magill Forceps (1)/Adult, Magill Forceps (1)/Pediatric, Oral Glucose Paste (1), Aspirin (1 bottle), Arterial Tourniquet (1)/Adult, Current Protocol Book, OB Kit (1), 3 lb Hammer, Fire Axe, 24” Crow Bar (1 each)OOS due to windshield

Vehicle 132: Mechanical

Vehicle 143: Passed with DeficienciesHead/Taillights, Pen Light (2), Pedi Wheel or Tape (1), IV Catheters (14, 16, 18, 20, 22, and 24 gauge) (5 each), IV Pressure Infuser (1)

Vehicle 135: Passed with DeficienciesNo Smoking Signs F/R, N.P.A. (12-34 fr) (6 Assorted)/A/P/I, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle 137: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 23, 2016 3/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

NORTHSTAR PARAMEDIC SERVICES - TUSCALOOSA / LIC # 330

Vehicle 144: Passed with DeficienciesHemostatic Agents (2), Nasal Cannulae with Tubing (3)/Pediatric, Magill Forceps (1)/Pediatric, Pedi Wheel or Tape (1), Haloperidol, Magnesium Sulfate

Vehicle 101: Verify Roster

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 23, 2016 4/4

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

PELHAM FIRE DEPARTMENT / LIC # 339

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

September 02, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle ENG-92: Passed with DeficienciesHemostatic Agents (2), Chest Needle Decompression Kit (1)

Vehicle ENG-93: Passed with DeficienciesLoad Lights, IV Catheters (14, 16, 18, 20, 22, and 24 gauge) (3 each)/A/P/I, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric

Vehicle ENG-94: Passed with DeficienciesGauze Pads (4x4) (50), Chest Seal (1), Non-Rebreathing Mask with Tubing (1)/Pediatric, Suction Catheters (6-18 fr) (3 assorted)/Pediatric, IV Catheters (14, 16, 18, 20, 22, and 24 gauge) (3 each)/A/P/I, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, Bougie Device (1)/Adult, Chest Needle Decompression Kit (1)

Vehicle ENG-95: Passed with DeficienciesBag-Valve Mask (BVM) (1)/Infant, IV Catheters (14, 16, 18, 20, 22, and 24 gauge) (3 each)/A/P/I, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, Bougie Device (1)/Adult

Vehicle QUINT 91: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

September 02, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

PRATTVILLE FIRE DEPARTMENT / LIC # 348

Veh Inspect Only?: NOwner Type: City - FirePassed

June 16, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

Med Control Hospital: PRATTVILLE BAPTIST HOSPITAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 16, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

PRATTVILLE FIRE DEPARTMENT / LIC # 348

VEHICLE INSPECTION SUMMARY:

Vehicle E2: Passed

Vehicle E3: Passed

Vehicle E-4: Passed

Vehicle 09-106: Passed

Vehicle R-1: Not Inspected

Vehicle 09-107: Passed

Vehicle 09-105: Passed

Vehicle R1: Passed

Vehicle 09-104: Passed

Vehicle 09-102: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 16, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SOUTHEAST SHELBY COUNTY RESCUE / LIC # 374

Veh Inspect Only?: NOwner Type: Non-Profit - EMSPassed with Deficiencies

August 18, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Please replace all quick clots within 10 days.See Protocol section 6.03 - Hemostatic agent - Acceptable devices.

Update Protocol Books inside ambulances.

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 18, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SOUTHEAST SHELBY COUNTY RESCUE / LIC # 374

VEHICLE INSPECTION SUMMARY:

Vehicle 89: Passed with DeficienciesLoad Lights, No Smoking Signs F/R, Hemostatic Agents (2)

Vehicle 86: Passed with DeficienciesHemostatic Agents (2)

Vehicle 81: Passed with DeficienciesHemostatic Agents (2), Magill Forceps (1)/Adult, Aspirin (1 bottle), Current Protocol Book

Vehicle RESCUE 1: Passed with DeficienciesNo Smoking Signs F/R, Hemostatic Agents (2), Non-Rebreathing Mask with Tubing (3)/Infant, BIAD (1)/Adult, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric

Vehicle RES-85: Passed with DeficienciesHemostatic Agents (2), Chest Seal (1), Magill Forceps (1)/Pediatric, Laryngoscope Blades (Miller size 0, 1, 2, 3, 4 && Macintosh sizes 1, 2, 3, 4) (1 set of each)/A/P/I

Vehicle 88: Passed with DeficienciesHemostatic Agents (2), Bandage Shears (1), Non-Rebreathing Mask with Tubing (3)/Infant

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 18, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SHOALS AMBULANCE - JEFFERSON / LIC # 1054

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed with Deficiencies

October 18, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

Update Web Management.307-Load light out, No Seat Belt signs, No Smoking signs, Missing signatures in Morphine Book, Missing Bougie, No Pediatric Oximetry306- Load Lights out, No Smoking signs, Bougie, Missing Valium, No Pediatric Oximetry308- No Smoking Signs, Dopamine Drip expired, Lidocaine Drip expired, No Pediatric Oximetry, ET Tubes expired 305- No Smoking Signs302- Need BLS and ALS Equipment divided out in different sealed cabinets.

Med Control Hospital: ELIZA COFFEE MEMORIAL

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Good Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 18, 2016 1/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SHOALS AMBULANCE - JEFFERSON / LIC # 1054

VEHICLE INSPECTION SUMMARY:

Vehicle 302: Passed with DeficienciesLoad Lights, No Smoking Signs F/R, Pulse Oximetry (1)/Pediatric, Pen Light (2), Magill Forceps (1)/Adult, Magill Forceps (1)/Pediatric, Sheets, Blankets, and Pillows (2 each), Albuterol Sulfate, Aspirin, Glucose, Oral paste (equivalent to Instant Glucose)*, Naloxone (equivalent Narcan), Nitroglycerin

Vehicle 304: Passed with DeficienciesHemostatic Agents (2), Pulse Oximetry (1)/Pediatric, Diphenhydramine, Diazepam (equivalent to Valium) or Lorazepam or both, Dopamine (equivalent to Intropin), Epinephrine (equivalent to Adrenalin) 1: 10,000 and 1:1,000, Haloperidol, Lidocaine HCL (equivalent to Xylocaine) Bolus, Magnesium Sulfate

Vehicle 303: Failed

Vehicle 305: Verify Roster

Vehicle 301: Failed

Vehicle 307: Verify Roster

Vehicle 308: Verify Roster

Vehicle SA 9: Verify Roster

Vehicle SA 10: Verify Roster

Vehicle 306: Verify Roster

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

October 18, 2016 2/2

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

SYLACAUGA AMBULANCE SERVICE / LIC # 389

Veh Inspect Only?: NOwner Type: For Profit - EMSPassed

June 22, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Transport

N

PROVIDER INSPECTION SUMMARY:

3175-InspectedPassed

Med Control Hospital: COOSA VALLEY MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle SA 8: Not Inspected

Truck mechanically out of service until futher notice. Blown engine.

Vehicle SA 2: Not Inspected

Vehicle 3173: Not Inspected

Vehicle mechanically out of service. Transmission shop

Vehicle SA 7: Passed

Vehicle SA 1: Passed

Vehicle 3174: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 22, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

TARRANT FIRE AND RESCUE / LIC # 394

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 17, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

PROVIDER INSPECTION SUMMARY:

Web Management needs to be update.

ENG 33 Not Listed in Web Management, Expired ET tubes size 2.0-2.5, No extra Larynoscope batteries, missing pediatric pulse oximetry Passed with deficiencies.ENG31 BLS Reserve Engine

Med Control Hospital: ST VINCENT'S EAST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle E 31: Verify Roster

Vehicle E 32: Passed with DeficienciesSuction Catheter (Tonsil Tip) (2)/Adult, Light (1), ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant

Vehicle R 77: Mechanical

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

August 17, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

THORSBY FIRE DEPARTMENT / LIC # 395

Veh Inspect Only?: NOwner Type: City - FirePassed

June 30, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle ENG-32: Passed

Vehicle ENG-31: Passed

Vehicle RES-3: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 30, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

TROY FIRE DEPARTMENT / LIC # 1017

Veh Inspect Only?: NOwner Type: County - FirePassed

June 24, 2016Jamie Gray

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: TROY REGIONAL MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Yes Adequate YesSanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle 01: Passed

Vehicle 02: Passed

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service , acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring itto the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be correctedwithin ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma , Standards and Enforcement Branch, inwriting, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorizedrepresentatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

June 24, 2016 1/1

PROVIDER INSPECTION FORMOFFICE OF EMS AND TRAUMA

WESTOVER MUNICIPAL FIRE DEPARTMENT / LIC # 979

Veh Inspect Only?: NOwner Type: City - FirePassed with Deficiencies

August 30, 2016Beverly Edwards

ALS/BLS: ALS1Outcome:

Date:Inspector:

Air Medical ALS:Transport: Non Transport

N

Med Control Hospital: SHELBY BAPTIST MEDICAL CENTER

Drug Area Locked: Space Allocation: Outdated Storage:Adequate Yes

DRUG SUMMARY:

Sanitation: ALS Inventory Log: Area Secured:Excellent Yes SecuredTemperature: Adequate Op Manual for Drugs:ALS Log Secure: Secured YesVentilation: Biohazard Plan:Adequate ALS Inventory Secure: Yes Yes

Yes Yes YesLicense Displayed: Personnel Records Filed: PCRs Properly Stored:

VEHICLE INSPECTION SUMMARY:

Vehicle B-297: Passed with DeficienciesNo Smoking Signs F/R, Hemostatic Agents (2), Pulse Oximetry (1)/Pediatric, Arterial Tourniquet (1)/Adult, CO2 Monitoring Equipment (2)/Pediatric, ET Tubes 2.0mm-3.5mm (uncuffed) (3)/Infant, ET Tubes 4.0mm-5.5mm (cuffed or uncuffed) (3)/Pediatric, ET Tubes 6.0mm-9.0mm (cuffed) (3)/Adult, Bougie Device (1)/Adult, Dopamine (equivalent to Intropin)

Provider RepresentativeInspector

I, the undersigned representative of the above referenced service, acknowledge receipt of a copy of this inspection form and understand that it is my responsibility to bring it to the immediate attention of the service owner or manager. I have been made aware of the noted deficiencies (if any exist) and understand that they must be corrected within ten days of the date of this report and that it is the responsibility of the service to notify the Office of EMS and Trauma, Standards and Enforcement Branch, in writing, of the date on which the deficiencies were corrected. I realize that the failure to promptly correct these deficiencies may subject the service and its authorized representatives to corrective action and penalties as set forth in Chapter 18, Section 22, 18-6, ct.seq., Code of Alabama, 1975, and the Office of EMS and Trauma Rules.

09/01/2016 1/1